Patient Chart: History

Version 14.8

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

Section
Description

1

Print button
The Print button prints the history report.
2
Past Medical History tab
The 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 button
The Reviewed button adds a log entry indicating a medical review of records was conducted.

4

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

6

Perinatal History tab
The 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: