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Updating Past Medical History

Version 14.19

Overview

You will learn about the section of the visit note that is used to document or review past medical history in this article. You will understand the fields to enable you to easily review and document additional information. To open a patient's past medical history:

Adding or Editing Past Medical History

  1. Navigate to a Patient Chart
  2. Click History in the Encounter section of the Window Navigation Panel. All previous documented past medical history is displayed.
  3. Click Past Medical History to view additional history points. 

  1. In the first column on the left, click N/A to mark + positive or click a second time to mark - negative.
  2. Double-click the Comments field and enter additional information if applicable.

Adding Custom Past Medical History Questions

  1. Within the Past Medical History tab, navigate to the bottom of the window.
  2. Select a Custom Question from the menu.
  3. Enter more information in the blank field if applicable.
  4. Click the Add button.

Repeat the steps for additional history questions.

Adding History to Problem List

  1. Select the History Question.
  2. Click the Add  button in the last column. A Warning pop-up box is displayed. 
  3. Click the New button. The Problem List window is displayed.

  1. Select a radio button for the Status of the problem. The default selection is Active. The Onset date defaults to the date the problem is entered. 
  2. Click the Onset Date field and enter a date or click the drop-down menu and select a date from the calendar.

  1. Click the Problem field. Enter name of the problem then press the Enter key or click the drop-down menu.
If 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.

  1. Once the problem is found, highlight 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.

Version 14.10

Overview

You will learn about the section of the visit note that is used to document or review past medical history in this article. You will understand the fields to enable you to easily review and document additional information. To open a patient's past medical history:

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

Adding or Editing Past Medical History

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

  1. In the first column on the left, click N/A to mark + positive or click a second time to mark - negative.
  2. Double-click the Comments field and enter additional information if applicable.
To add history questions that are not included:
  1. Click the Custom question drop-down arrow.
  2. Select Past Medical History from the drop-down menu.
  3. Enter the History Question.
  4. Click the Add Questionbutton.


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. In the Warning pop-up box, click the New button.

  1. Select a radio button for the Status.
  2. Select or enter the Onset date.
  3. Enter the Name or Code of the SNOMED code in the Problem field and press the Enter key or click the drop-down arrow.
    1. Click to select a Code.
      or
      Select the Full Search button.

  1. Select a radio button 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. Select Stage/Severity, Quality of life and Symptoms from the drop-down menus.

  1. Enter additional comments or pertinent information in the Notes field.
  2. Select a Visibility Level from the drop-down menu if it is not Any staff member.