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Enter a Patient's History

Version 20.7

Overview

A patient's History is broken down into 6 different tabs in the Patient Chart (and Visit Note), represented in the first 6 expandable sections below. The instructions below assume that a patient's History is being entered during the course of a Visit, but History can also be entered directly into the History section of the Patient Chart, outside of the context of a Visit Note.

Click + to expand the sections below.

Past Medical History

Add Past Medical History

  1. From within the Visit Note, click History, and then the Past Medical History tab. All previously documented Past Medical History is displayed.
  2. Click the Past Medical History header to view additional history questions.
  3. In the + / - column, click N/A to mark + positive or click a second time to mark - negative.
  4. If applicable, click in the Comments field and enter additional information.
  5. Click the Save button .

Family History

Add Family History

  1. From within the Visit Note, click History, and then the Family tab.    
  2. Click the Add button.
  3. In the Family Member drop-down, select the family member whose history is being entered.

  1. In the Problem field, click the Problem List button to choose from a list of Problems, or enter the Problem, and click the Search button to search for and select the Problem.

  1. If known, select the age of diagnosis in the Dx Age field. Otherwise, leave the default selection of Unknown.
  2. Type in any notes pertaining to problem into the Notes field.
  3. Confirm the Copy To field includes the appropriate Family Members.
  4. Click the Save button  to save.

Social History

Add Social History

  1. From within the Visit Note, click History, and then the Social tab. All previously documented Social History is displayed.
  2. Click the Social History header to view additional history questions.
  3. In the + / - column, click N/A to mark + positive or click a second time to mark - negative.
  4. If applicable, click in the Comments field and enter additional information.
  5. Click the Save button  to save.

Newborn History

Add Newborn History

  1. From within the Visit Note, click History, and then the Newborn tab. All previously documented Newborn History is displayed.
  2. Click the Newborn History header to view additional history questions, or select the Show all questions checkbox to include Maternal Perinatal History.
  3. In the + / - column, click N/A to mark + positive or click a second time to mark - negative.
  4. If applicable, click in the Comments field and enter additional information.
  5. Click the Save button  to save.

Birth Info

Add Birth Info

  1. From within the Visit Note, click History, and then the Birth Info tab.
  2. Complete the fields with the documentation you have been provided based on the descriptions in the table below.
FieldDescription
Birth timeEnter the time of the child's birth. The format is HH:MM AM/PM. To document this in military time, select the 24hr checkbox.
Part of a multiple birthSelect the checkbox if the child was part of a multiple birth.
ApgarsEnter the Agpars score as a numeric value from 1-10.
Gestational ageSelect the Gestational age from the drop-down list. Gestational age is important when a child was born premature. An entry for a premature Gestational age will prompt for the preemie growth chart when evaluating growth measurements.
Synagis indicatedSelect the checkbox if Synagis is indicated. When selecting this checkbox, the Immunization record will be updated for this child setting the Synagis indicator.
Type of deliverySelect the type of delivery from the drop-down list.
FeedingSelect the feeding method from the drop-down list.
Infant blood typeSelect the infant blood type from the drop-down list.
CoombsSelect POSITIVE or NEGATIVE from the drop-down list.
Hearing screenSelect the hearing screen result from the drop-down list.
Newborn screen #If known, enter the Newborn screen #.
Adopted at monthsSelect the Adopted checkbox if the child was adopted, and enter the numeric value for how old the child was at adoption (months).

  1. In the Birth Location section, click the drop-down for Birth place and select from the list. If the birth place is not in the list, you may type the name in the text field below.
  2. In the Birth Measurement section, select the unit of measurement, and enter the birth length, weight and head circumference
  3. In the Discharge Measurements section, enter the discharge date, length, weight and head circumference.
  4. Click the Save button to save.

Maternal/Pregnancy

  1. From within the Visit Note, click History, and then the Maternal/Pregnancy tab.
  2. Make selections from the drop-downs to complete the Maternal Blood Type / Tests and Family of Origins fields. The inclusion of the mother's Maiden Name is important for immunization registries.
  3. Click the Save buttonto save.

Add Custom History Questions (Past Medical, Social, Newborn)

  1. Navigate to Custom Question located at the bottom of the Past Medical, Social, or Newborn History window, and select Past Medical History, Social History, or Newborn History from the drop-down list, depending on which History you are entering.
  2. Enter the Custom Question in the blank field, and click the Add button.
  3. Repeat the steps for additional history questions.
  4. Click the Save button.

Add History to Problem List (Past Medical, Social, Newborn)

  1. Navigate to the appropriate History tab.
  2. Click to select the History Question.
  3. Click the Add button and select from the following options:
  • New: Starts a new problem. The Problem List window is displayed upon clicking the New button. Proceed to step 4.
  • Attach: Attaches the question to an existing problem. The patient's Problems are displayed, where you will select the appropriate problem and click OK.
  1. Select a radio button for the Status of the problem. The default selection is Active.
  2. Click the Onset Date field and enter a date or click the drop-down menu and select a date from the calendar. The default selection is the current date.
  3. Click the Problem field. Enter name of the problem then press the Enter key or click the drop-down menu.

NoteIf the problem is not found:

  1. Click the Full Search button.
  2. To expand the search, select the Complete radio button.
  3. If the problem is not in the complete list, select the Master radio button.
  4. Once the problem is found, highlight it and click the Select button.

  1. Click the Code and click the Select button.
  2. Click the ICD code field. Enter the Name or Code then press the Enter key or click the drop-down menu.
  3. Click on the Code and click the Select button.
  4. (Optional) In the Refer/coord: field, enter the Name of the specialist or facility that is handling the care for the entered problem. You may also:
  • Click the Address Book button  and search and select from the address book entries
  • Or, click the Coordination of Care button  and select from the list that has been associated to the patients record.
  1. (Optional) Select an options from the Stage/Severity, Quality of life and Symptoms drop-down menus.
  2. (Optional) Enter any additional comments or pertinent information in the Notes field or click the Phrase Construction button for help with the Note.
  3. (Optional) Select an option from the  Visibility drop-down menu if the privacy level is higher than Any staff member.