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:

  1. Click the Patient Chart button in the Clinical, Practice Management, or Billing tab.
  2. Click History.

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.
  2. 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 button to save the entry.

To include the selection in the Problem List:

  1. Click the Add Entry button in the last column of the row of the entry.

  1. Click the New button.

  1. Select Status.
  2. Select the Onset date.

  1. Enter the problem or enter the SNOMED code in the Problem field and press the Enter key on your keyboard or click the dropdown arrow.
  2. Click on the applicable code, and then click Select.
    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 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.