The "Presentation" text block is used in problem oriented charting (POC) outputs. It appears at the top of the POC sidebar, giving a quick sense of how the patient presented and why.
The presentation block can be inserted at the top of progress notes (e.g., when those serve as a weekly summary) and it is incorporated into all "advanced" summative documentation (admission history, discharge summary, consult, etc.).
Like other POC building blocks, the patient presentation is interactive. Click on any dark blue text to activate a pop-up "SmartForm" for editing the underlying structured data:
- Help - Embedded help links are signified with the "?" character, which can be selected to access more information about the intent and use of patient presentation data.
- Buttons - Facilitate rapid entry of commonly used options for a particular data element. These can be ignored and free text entered in the provided box.
- Edit - Text boxes are provided for the five presentation data elements (how the patient presented, from where, with what complaint and what clinical intent; with optional indication of COVID-19 vaccination status).
- Accept/Cancel - Buttons determine whether edits are saved or not.