Past Medical History

Version 14.8


This section will introduce the users to the section of the visit note 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.

History Tab

Add or Edit the Past Medical History

  1. Click the heading Past Medical History to view additional history points. 

Past Medical History tab

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

Past Medical History tab

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 plus button to save the entry.

Past Medical History tab: Custom Question

To include the selection in the Problem List:

  1. Click the Green Plus button  in the row of the entry, in the last column.

Past Medical History tab

  1. Click the New button.

Problem List Window

  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.

Problem List Window: Diagnosis window

  1. Click to select a code.
    Select the Full Search button.

Problem List Window: Diagnosis window

  1. Click on the radio buttons in the window to expand the search.

SNOMED Code/Description window 

  1. Click the Address Book button  or Click the Coordination of Care button   and select the appropriate provider or facility if applicable.

Address Book Window

Patient Information: Coord of Care Window

  1. Click the drop-down arrows to select Stage/Severity, Quality of life and Symptoms.

Problem List

  1. Add additional comments or pertinent information in the Notes field.
  2. Select a Visibility Level if other than Any staff member.