We are currently updating the OP Help Center content for the release of OP 14.19 or OP 19. OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Past Medical History

Version 14.19

Overview

This section will introduce users to the section of the visit note that is used to document or review past medical history. The user will be guided through the fields to easily review and document additional information. To open a patient's past medical history:

Add or Edit Past Medical History

  1. From an open well visit note, click History.
  2. All previous documented past medical history displays.
  3. Click the heading Past Medical History to view additional history points. 

  1. Click N/A to mark + positive or click a second time to mark - negative.
  2. Add additional information into the Comments field.

Add Custom Past Medical History Questions

  1. Click into the Custom question field.
  2. Select Past Medical History.
  3. Type the history question.
  4. Click the Add button.
  5. Repeat the steps for additional history questions.

Add History to Problem List

  1. Select the history question
  2. Click the Add  button located in the last column.
  3. Warning displays, click the New button.

  1. Select the Status of the problem, default selection is Active.
  2. Onset date will default to the date the problem is entered. Click into the field and type a date or click the drop-down and select a date from the calendar.

  1. Click into the Problem field. Begin typing the name of the problem then press the Enter key or click the drop-down arrow.
If the problem is not found:
  1. Click the Full Search button.
  2. To expand the search click the Complete radio button.
  3. If the problem is not in the complete list, click the Master radio button.

  1. Once the problem is found, highlight and click the Select button.
  1. Click on the code and click Select.
  2. Click into the ICD code field. Begin typing the name or code then press the Enter key or click the drop-down arrow.
  3. Click on the code and click Select.
  4. (Optional) In the Refer/coord: field, type 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) Click the drop-down arrows to select Stage/Severity, Quality of life and Symptoms.
  2. (Optional) Add additional comments or pertinent information in the Notes field.
  3. (Optional) Click the drop-down for Visibility: if the privacy level is higher than Any staff member.
Version 14.10

Overview

This section will introduce users to the section of the visit note that is used to document or review past medical history. The user will be guided through the fields to easily review and document additional information. 

To open a patient's past medical history click the History tab on the patient's chart.

Add or Edit the Past Medical History

  1. Click the heading Past Medical History to view additional history points. 
    1. Click N/A to mark + positive or click a second time to mark - negative.

    • Add additional information into the Comments field.
  • To add history questions that are not included:
    1. Click the Custom question drop-down arrow.
    2. Select Past Medical History.
    3. Type the history question.
    4. Click the Add Questionbutton to save the entry.


    To include the selection in the Problem List:

    1. Click the Add Entry button in the row of the entry, in the last column.
    1. Click the New button.
    1. Select the Status.
    2. Select the Onset date.
    3. Type the name or code of the SNOMED code in the Problem field and press the Enter key on your keyboard or the drop-down arrow.
    1. Click to select a code.
      or
      Select the Full Search button.
    1. Click on the radio buttons in the window to expand the search.
    1. Click the Address Book button  or the Coordination of Care button   and select the appropriate provider or facility if applicable.
    1. Click the dropdown arrows to select Stage/Severity, Quality of life and Symptoms.
    1. Add additional comments or pertinent information in the Notes field.
    2. Select a Visibility Level if other than Any staff member.