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.
- Click the History button.
- Past Medical History previously entered display.
- To add or edit the past medical history, do one of the following.
- To view additional history points, click the heading Past Medical History.
- 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 not included, click the Custom question drop-down arrow.
- Click to select Past Medical History.
- Type the history question.
- Click the plus icon to save the entry.
- If the selection is to be included in the Problem List, follow the steps below.
- Click the plus icon.
- Add or Edit Problem list dialog box displays.
- Click the New button.
- The Problem List window displays.
- Select the Status and Onset date in the Problem list section
- Begin typing the name or code of the diagnosis code
- Press the Enter key
- The ICD-10 window display
- Click to select a code
- If the code is not found, select the Full Search button
- ICD-10 Code table displays
- Enter a referral or coordination of care source.
- Click the Address Book button.
Click the Coordination of Care button.
- Click the drop-down arrows to select Stage/Severity, Quality of life and Symptoms.
- Add additional comments or pertinent information in the Notes field.
- Select a Visibility Level if other than Any staff member.
- Click the Save button.