Past Medical History

Version 14.8

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.