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 (Encounter)

Version 14.19

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. 

  1. From within the Encounter note, click History
  2. If not already selected, click the Past Medical History tab.

  1. To add or edit the past medical history, do the following:
  • Click N/A once to mark positive (+) or twice to mark negative (-)
  • Add additional information into the Comments field.

Note: Upon saving and refreshing the Past Medical history, the list of History Questions will be reduced to only those which have been assessed. To see all Past Medical History questions, click the bolded header Past Medical History

  1. To add history questions not included:
  1. Click the Custom question dropdown located at the bottom of the window, and select Past Medical History.
  2. Type the history question.
  3. Click Add.


  1. If the selection is to be included in the Problem List, click the Add button and confirm if you want to start a new problem or attach to an existing problem.

  1. Proceed with entering the Problem List information.
Version 14.10

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. 

  1. Click the History button.
  2. Past Medical History previously entered display.


  1. 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.

  1. To add history questions not included, click the Custom question drop-down arrow.
  • Click to select Past Medical History.
  • Type the history question.

  1. Click the plus icon to save the entry. 
  2. 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

  1. Enter a referral or coordination of care source.
  2. Click the Address Book button.
    OR
    Click the Coordination of Care button.

  1.  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.