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.

Patient Chart: History

Version 14.19

About Patient Chart: History

Path: Clinical tab > Patient Chart button > History
Path: Practice Management tab > Patient Chart button > History
Path: Billing tab > Patient Chart button > History

The Patient Chart is the central point of access to all areas of a patient's complete Medical record.  Use the Patient Chart to access and maintain patient records.  

The History window documents a patient’s history. The window captures and displays multiple sections of the patient's history (Past Medical History, Family Medical History, Social History, and Perinatal History) in a simple-to-use and easy-to-read format.


Note:  Just like a paper chart, the Office Practicum chart, and other windows in Office Practicum, contain personal health information that should be kept confidential. You should treat all windows in Office Practicum (like F8 Chart) just like you would treat a paper record of patient health information, never leaving that record out in the open for others to see. More specifically, you should always close all windows on your screen and log out of Office Practicum when you are done at your workstation.

Patient Chart: History Map

Number

SectionDescription
1
Past Medical tabThe Past Medical tab documents or reviews a patient’s past medical history. You can link or add history to the problem list from this area.
2
Family tabThe Family  tab documents or reviews a patient’s family medical history.  Family members are linked based upon how they are documented in the Contacts field.
3
Social tabThe Social tab documents a patient’s social history such as pets, smokers in the home, siblings, visitation status, etc.
4
Perinatal History tabsThe Perinatal History tab documents notes for newborn history, birth info, and maternal/pregnancy history.
5
Mark Reviewed button
The Mark Reviewed button adds a log entry indicating a medical review of records was conducted.

6

Print buttonThe Print button prints the history report.
7
History buttonThe History button opens the History window in the patient's chart.
Version 14.10

About Patient Chart: History Tab

Path: Smart Toolbar > Chart button > History tab

The Patient Chart is the central point of access to all areas of a patient's complete Medical record.  Use the Patient Chart to access and maintain patient records.  

The History tab documents a patient’s history. The Patient History captures and displays multiple sections of the patient's history (Past Medical History, Family Medical History, Social History, and Perinatal History) in a simple-to-use and easy-to-read format.


Note:  Just like a paper chart, the Office Practicum chart, and other windows in Office Practicum, contain personal health information that should be kept confidential. You should treat all windows in Office Practicum (like F8 Chart) just like you would treat a paper record of patient health information, never leaving that record out in the open for others to see. More specifically, you should always close all windows on your screen and log out of Office Practicum when you are done at your workstation.

Patient Chart: History Tab Map

Number

SectionDescription

1

Print buttonThe Print button prints the history report.
2
Past Medical History tabThe Past Medical History tab documents or reviews a patient’s past medical history. You can link or add history to the problem list from this area.
3
Reviewed buttonThe Reviewed button adds a log entry indicating a medical review of records was conducted.

4

Family History tabThe Family History tab documents or reviews a patient’s family medical history.  Family members are linked based upon how they are documented in the Contacts field.

5

Social History tabThe Social History tab documents a patient’s social history such as pets, smokers in the home, siblings, visitation status, etc.

6

Perinatal History tabThe Perinatal History tab documents notes for newborn history, birth info, neonatal course, and maternal/pregnancy history.
7
Left tabs

The left tabs open a different section within the patient’s medical records.  The Patient Chart contains the following left tabs: