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Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Primary Care Physical Health
Hysio keeps the client's account, recorded measurements, evaluation and plan separate in chronic care, with room for diabetes, cardiovascular risk management (CVRM), COPD, asthma and lifestyle.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Record the conversation and clearly state your own findings and agreed actions.
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More attention for the conversation, less typing afterwards.
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Quick answer
Hysio keeps the client's account, recorded measurements, evaluation and plan separate in chronic care, with room for diabetes, cardiovascular risk management (CVRM), COPD, asthma and lifestyle.
An annual review, a chronic care consultation and a conversation about self-management each have their own structure. HbA1c, blood pressure and lung function sit with their measurement moment, separate from your evaluation.
Hysio Physical Health Chronic Care Consultation is for a chronic care consultation with the client's account, actually measured values, evaluation and plan. The format follows Summary, S. Subjective, O. Objective, E. Evaluation and P. Plan. You keep what the client tells you about symptoms or lifestyle separate from blood pressure, weight, glucose or other measurements that were actually carried out. [1] [2] [6] [7] [3]
Hysio Physical Health Annual Review and Intake is for an initial inventory or periodic review of chronic care. The set-up organises the summary, subjective account, objective data, evaluation, plan and an additional section. A diabetes value, CVRM risk data or inhaler discussion only goes into the report when the source actually contains that information and you assess its meaning. [1] [2] [6] [7] [4]
Hysio Physical Health Self-Management Evaluation is for looking back on agreed goals, behaviour, perceived burden, measurements, evaluation and follow-up. A goal is not automatically declared achieved because a client sounds motivated or a value changes. You decide which goals were agreed, how progress is assessed and which plan has been recorded with the client. [1] [2] [6] [7] [5]
The Chronic Care Consultation is intended for a regular contact about ongoing care, the Annual Review and Intake for an initial or periodic broad inventory, and the Self-Management Evaluation for a focused look back on goals and self-direction. Look at the purpose of contact and not only at the condition. If in doubt, you describe the actual contact and leave a missing goal status or measurement open. [1] [2] [6] [7] [3]
In a report you can place the client's account, diabetes-related measurements, perceived symptoms, evaluation and plan clearly side by side. The NHG-Standaard Diabetes mellitus type 2 remains the clinical source for professional choices; Hysio does not make a treatment decision or set a target value. For example, you check whether an HbA1c was actually measured, which source it comes from and what you agree about it professionally. [1] [2] [6] [7] [3]
CVRM (cardiovascular risk management) can determine the purpose of contact and the relevant context, for example with blood pressure, lifestyle or cardiovascular risk factors. Only record values, risk information and agreements that were actually discussed or measured. You use the NHG source and the local registration agreement for the professional interpretation. Hysio does not derive a risk category, medication decision or treatment priority from isolated words. [1] [2] [6] [7] [3]
Describe the perceived breathlessness, inhaler use, checks carried out and self-care discussed as separate sources. Only record a lung function or measured value when it was actually obtained, with date and method. You assess whether an inhaler problem, exacerbation question or follow-up fits the professional context and leave a medical conclusion to the authorised practitioner. [1] [2] [6] [7] [4]
Hysio does not fill in blood pressure, glucose, weight, diagnosis, medication decision or goal status. Hysio can organise the sources of a chronic care consultation. Which measurement was actually carried out and how it is assessed within the care programme is for you to decide; the plan follows from that assessment. A missing value therefore stays open, and a professional conclusion does not arise from an empty space. [1] [2] [6] [7] [3]
Put what the client tells you about symptoms, lifestyle or daily functioning in the subjective section. Put blood pressure, weight, glucose or another measurement that was actually carried out in the objective section, with date, source and context. You assess the meaning in the evaluation and prevent a perceived improvement or an isolated value from being presented as an established treatment goal. [1] [2] [6] [7] [3]
Record the goal as it was discussed with the client, and add the timeframe or the agreed measure when it has actually been set. Then describe progress and the client's perspective without automatically concluding that the goal has been achieved. In the Self-Management Evaluation, goal, progress, evaluation and plan stay separate. Together with the client and the team, you decide which assessment and follow-up action are justified. [1] [2] [6] [7] [5]
The Annual Review and Intake organises the request for help, relevant history, objective measurements, professional evaluation and the plan. This way diabetes care and CVRM can be described clearly per contact without inventing values or goals. You check the source, measurement date, unit and the local care programme agreement yourself, and you decide which information counts for this annual review. That way, admin with AI in an annual review is limited to dictating and reading through. [1] [2] [8] [10] [11] [4]
Describe what the client does themselves, which obstacles are experienced, which support was discussed and what was concretely agreed. Make clear whether something is a statement by the client, an observation or your professional evaluation. You decide whether a goal is adjusted, continued or discussed again, and you do not let assumed motivation pass for a result. [1] [2] [8] [10] [11] [5]
Only include data that are relevant to the contact and the care question, such as symptoms, lifestyle, agreed checks, actually measured values, medication that was discussed and the follow-up. You keep the source and date visible for every item and prevent an old result from being read as a current measurement. The professional meaning belongs in the POH-Somatiek professional's evaluation. [1] [2] [8] [10] [11] [3]
Write that the measurement was not carried out or was not available and only record the agreed follow-up action. Do not fill in a value based on an earlier result, an expectation or a guideline. In the annual review, the measurement stays separate from the evaluation and plan. You assess whether measuring again is needed and who carries out that action, without classing the missing value as normal or abnormal. [1] [2] [8] [10] [11] [4]
A conversation about lifestyle can be recorded within the Chronic Care Consultation when it is part of the ongoing contact. If you are looking back on an agreed lifestyle goal, the Self-Management Evaluation fits better. You describe the client's own words, the options discussed and the concrete plan. Hysio does not choose an intervention, does not predict an effect and does not decide whether the client has changed enough. [1] [2] [8] [10] [11] [5]
Record which inhaler or procedure was actually discussed or observed, what the client demonstrates and which explanation or agreement follows. Do not use a general assumption that the technique is right or wrong when you have not seen it. You describe observation, the client's question and professional assessment separately and check whether a follow-up check or consultation with the GP has been agreed. [1] [2] [8] [10] [11] [4]
Place the original goal, the period, the client's perspective and the relevant measurement or observation data side by side. Describe a change as a change, not automatically as success or failure. You determine the professional evaluation, discuss the follow-up with the client and only record an adjusted plan when that has actually been agreed. [1] [2] [8] [10] [11] [5]
The professional evaluation connects the source information that is actually available to the purpose of the contact. For example, you can state how symptoms, measurements and self-management relate to each other, but only when that assessment has been made. The format does not prescribe that conclusion. You check that an evaluation does not accidentally contain the client's wording, an old value or a diagnosis that was not discussed. [1] [2] [8] [10] [11] [3]
Record which action, check, explanation or referral was agreed, by whom and within which timeframe. Keep a proposed option separate from a decision made with the client or GP. You check whether the plan fits the current source information and leave medication or treatment choices to the authorised healthcare professional who made them. [1] [2] [8] [10] [11] [4]
A client goal is about what someone considers important themselves, while a practice or care programme goal can be a professional or organisational agreement. Record both with their own source and do not phrase them as if they mean the same thing. You discuss how the goals relate to each other and only record a joint follow-up agreement when it has really been made. [1] [2] [8] [10] [11] [5]
The NHG guideline ADEPD offers a current framework for relevant, adequate and structured record keeping in general practice. The POH-Somatiek translates this within the local care programmes into recognisable contact information, measurements, evaluation and plan. Hysio does not take over that local agreement. You check which data are needed and keep the source of the client's account and the measurement visible. A dictated annual review must also meet that framework; voice-driven reporting does not change that. [1] [2] [9] [12] [13] [3]
ICPC is a classification and coding context within the HIS, not a conclusion that arises from free text. Only use a code when you or the authorised responsible professional chooses it as appropriate according to the local agreement. The Hysio formats do not fill in any ICPC code. You check the episode, complaint, code and source and do not let coding replace the professional evaluation. [1] [2] [9] [12] [13] [4]
Record which information is shared for which care goal, with whom, when consent was asked and what the outcome was, insofar as that is needed in this situation. Silence or taking part in a consultation is not automatically full consent. You follow the WGBO, the privacy procedure and the local exchange agreement and keep any restriction of consent visible to the care team. [1] [2] [9] [12] [13] [5]
For a medical record, the main rule is a minimum retention period of twenty years from the last change, with exceptions and possible longer retention. Hysio does not set that period and does not determine which local archiving route applies. You follow the record procedure of general practice and make sure that a relevant measurement, evaluation or agreement is saved recognisably as record information. [1] [2] [9] [12] [13] [3]
Limit the report to information that is needed for the agreed care goal and check who has access. Take extra care with diagnoses, medication, lifestyle and values that are not needed outside the direct contact. You use a designated route, check the recipient and consent and follow the local procedure for logging and correction. [1] [2] [9] [12] [13] [5]
The Competentieprofiel POH 2025 (POH competency profile) describes, among other things, professional responsibility, client safety, self-management, collaboration and record keeping. It is not an automatic declaration of authority for every action or every care decision. You work within your own competence and local task agreements and record a consultation or referral when the situation falls outside your role. [1] [2] [9] [12] [13] [3]
Use the complaint, measurement and observation as the source gives them and set a professional conclusion apart. A high blood pressure value, breathlessness or abnormal glucose is not in itself a diagnosis. You assess the situation using the applicable guideline and local collaboration and only record a diagnosis or policy when it has been established by the authorised healthcare professional. [1] [2] [9] [12] [13] [3]
Record the reason, relevant source information, the concrete question, who took part in the consultation, the answer or decision and the agreed action. Keep your own evaluation next to the GP's decision, not in its place. You check the date, status and who is responsible for follow-up and keep a consultation point that has not yet been answered visible in the record. [1] [2] [9] [12] [13] [4]
Record factually who is making the complaint, which contact it relates to, what happened according to the person reporting it and which complaints route has been agreed. Do not add any judgement or medical conclusion. The Wkkgz (Dutch Healthcare Quality, Complaints and Disputes Act) provides the framework for good care, incidents and complaints; the local procedure determines how it is handled. You keep the complaint, the internal assessment and any follow-up action apart. [1] [2] [9] [12] [13] [5]
Describe which lifestyle topics the client raises, which information you discussed and which agreement was actually made. Record advice as advice and not as a change that has been made or a goal that has been achieved. You keep the client's choice, professional evaluation and follow-up action separate and check whether a colleague can understand the text without extra assumptions. [1] [2] [9] [12] [13] [4]
Only include measurements that were actually carried out in this contact or supplied by a reliable source. Record the type of measurement, value, unit, date, method and relevant circumstances. A blood pressure, HbA1c, weight or saturation without a source or moment is not traceable. You assess the clinical meaning and do not let Hysio fill in a missing value or target value. [1] [2] [10] [11] [14] [3]
Only copy the HbA1c value when it comes from a source, and state the date and unit as registered. Record the agreed goal or the professional assessment separately, when it has actually been discussed. You use the current diabetes guideline for the professional interpretation and prevent Hysio from classing a value as good, poor or achieved without your assessment. [1] [2] [10] [11] [14] [4]
Enter the value as earlier information mentioned by the client and make clear that it is not a current measurement in this contact. Check whether a reliable source or new measurement is available when that fits the way you work. The Chronic Care Consultation format does not present it as current. You decide which value is relevant for the evaluation and record the follow-up separately. [1] [2] [10] [11] [14] [3]
State the name of the questionnaire, the date it was completed, who gave the answers and the score as actually recorded. Only describe what the score means for this contact in a professional evaluation. You check that the version and context are known and do not treat a score as a diagnosis, goal status or replacement for the conversation with the client. [1] [2] [10] [11] [14] [5]
Place both sources clearly side by side and record which additional question, repeated measurement or professional assessment has been agreed. Do not automatically choose the value that seems most plausible. You decide whether the contradiction has consequences for the care plan and make the evaluation match what has actually been assessed. [1] [2] [10] [11] [14] [3]
No, Hysio does not derive a care goal, target value or goal status from a guideline or an isolated measured value. The formats can organise a stated goal and progress. You discuss the goal with the client, use the appropriate NHG guideline and only record a change or decision when that has actually been agreed. [1] [2] [10] [11] [14] [5]
Record which medication the client mentions, what was actually discussed and which decision was made by the authorised healthcare professional. A question, a proposal and a decision that has been carried out are different things. You check the name, dosage and source and do not let Hysio fill in a medication choice or change because a symptom might fit it. [1] [2] [10] [11] [14] [4]
Describe what the client will do themselves, when, with what support and when feedback follows, if that has actually been agreed. Do not present an idea or option as a decision. You check whether the agreement is understandable, who follows up and how the client's perspective will be evaluated later, without promising the expected outcome in advance. [1] [2] [10] [11] [14] [5]
Check whether the request for help, relevant source information, measured values with their moment, professional evaluation and plan can be distinguished from one another. Also look at the episode or contact, any medication discussion, goal status and open actions. You correct factual errors and only approve when a colleague can trace the text back to the real contact. With voice-driven admin, only the typing shifts, not this check. [1] [2] [10] [11] [14] [3]
Leave a measured value without professional interpretation when the source only contains the value or when the assessment has not yet been discussed. Record the type, unit, moment and source and make an open follow-up question visible. You assess yourself whether consultation is needed and prevent Hysio from turning a number into a diagnosis, target value or goal status. [1] [2] [10] [11] [14] [3]
For POH-Somatiek, the Hysio pricing page lists a Starter plan of €20 per month, excl. VAT. This amount says nothing about the local set-up or the professional assessment of the three POH-Somatiek formats. Compare the current price with your practice process and first assess whether source checking, measured values, goal status and professional evaluation fit well within the way you work. [1] [2] [15] [3]
Determine which health data are needed for the contact, who may see them and with which healthcare professional you may share them. Record consent, purpose and recipient when the situation requires it. Hysio does not change those agreements. You use the practice's privacy procedure and prevent a spoken value or lifestyle detail from ending up in a broader handover without being checked. [1] [2] [16] [17] [5]
You can type manually, use your own template within the HIS or assess another dictation solution that supports human review. Every route requires checking the source, measurement, professional evaluation and plan. So compare whether diabetes, CVRM, COPD or asthma information is easier to find, without a shorter input time coming at the expense of the professional assessment. Voice-driven reporting is one of those routes; you make the comparison yourself. [1] [2] [3]
The current product information gives POH-Somatiek a general Hysio trial of 14 days. Do not use that trial to have a care goal or measured value assessed automatically. Choose a limited number of chronic care contacts, agree on POH and GP review and record corrections and open points. Then discuss whether the structure stays safe and understandable for the client, the POH-Somatiek professional and the GP. [1] [2] [15] [4]
No, an automatic connection with every HIS or chain-of-care information system has not been demonstrated. The documentation formats offer a content structure, but no guarantee about the transfer of values, codes or care plans. Check per practice which route is permitted, who reviews the text and how the source, measurement date and professional evaluation are preserved in any transfer. [1] [2] [5]
Have the POH-Somatiek professional check whether the client's account, measurement, evaluation and plan are correct, and have the GP review them when the local agreement requires it. Check medication, abnormal values, goal status and open consultation points extra carefully. Hysio does not take over any medical assessment. Agree in advance who corrects and who authorises, as well as the moment when an additional measurement or a conversation with the GP is needed. [1] [2] [3]
First check the original measurement source, date, unit and method. Correct the value according to the record procedure and keep visible when and by whom the correction was made. Do not change the professional evaluation at the same time without assessing it again. You check whether the error had consequences for the plan or consultation and inform the healthcare professional involved when needed. [1] [2] [4]
Record which part is missing, for example the agreed timeframe, measured value, client priority or follow-up action. Ask about the missing point specifically when that fits the contact, and otherwise leave it marked as open. You assess whether the evaluation can be completed and who discusses the next step with the client. [1] [2] [5]
Measure the time for recording, checking, correcting and finding values, goals and agreements separately. Also check that the POH-Somatiek professional does not take an old measurement to be current and that the GP can follow the plan quickly. No POH-Somatiek-specific time savings have been established. Use anonymised examples and stop if the structure causes extra checking work or doubt about goal status. [1] [2] [3]
Start with one clearly recognisable purpose of contact, for example an annual review, and agree which measured values, sources, goals and evaluations must be checked. Then test a self-management evaluation with a missing value and a question for the GP. Only expand once the POH-Somatiek professional and the GP have assessed the content, privacy and correction route. [1] [2] [4]
Hysio creates the report. You remain responsible for what you save in the record.