Handling Patient Medical History

Adding Medical Histories

Only users with the proper security settings can enter a medical history. For more information, see Setting Medical History Security.

• When you enter or edit information in the Medical History window, the associated patient record is locked. You can view the Medical History window without locking the patient record.

To add medical history information for a patient:

1. Select an option:

2. From the List menu:Select Patient. The Patient List window is displayed. Double-click a patient in the list.

3. In the Power bar:Select Patient List Window. The Patient List window is displayed. Double-click a patient in the list.

4. In the Account List or Account window:Select Patients from the Options menu in the Express bar. A Patient List window containing all of the patients associated with the account is displayed. Select a patient.

5. In the InOffice window:Select Patient from the Options menu in the Express bar. The Patient List window is displayed. Double-click a patient in the list.

6. In any window:Press Ctrl + O. The Patient List window is displayed. Double-click a patient in the list.

The patient is displayed in the Patient window.

2. Click OK and select Clinical Management > Patient Medical History from the Options menu in the Express bar.
   
   OR
   
   In the patient chart, hover over the Medical Conditions, Allergies, or Medicines section of the patient banner, and click the link.
   
   The Medical History window is displayed. If medical history information exists for the patient, this information is displayed.

3. Click Update. The current day’s date is displayed in the Medical History Recorded On field.

4. Type the physician’s name and phone number in the appropriate fields.

5. If the patient is currently taking prescription or non-prescription medication, click Add Drug and select the drug from the list.

3. The medication must be entered in the Drug window before you can add it to a medical history. For more information, see Adding Prescription Drugs.

6. Select an option:

7. To indicate the patient is allergic to a substance:Select Yes next to the substance text in the Allergies section.

8. To indicate the patient is not allergic to a substance:Select No next to the substance text in the Allergies section.

9. To add additional information about a patient allergy:Type the information in the Other field.

10. To include heart rate, blood pressure, height, weight, or smoking-related patient information to the medical history:Type the information in the Miscellaneous section.

11. To include birth control, pregnancy, or nursing information to the medical history:Select an option in the For women only section.

• The For women only section is enabled only if Female or Unknown is selected from the Sex drop-down list on the Info tab of the Patient window.

7. Press Ctrl + Tab to make the Conditions tab the active window. Medical condition information is contained on this tab. Medical conditions that trigger a medical alert are displayed in red text.

8. Select an option:

9. To indicate the patient suffers from a medical condition:Select Yes next to the condition text.

10. To indicate the patient does not suffer from a medical condition:Select No next to the condition text.

• To manipulate the condition information that is displayed on the tab, see Understanding Medical Conditions.

9. Press Ctrl + Tab to make the Other tab the active window. Additional patient medical condition information is contained on this tab.

10. To indicate that the patient is experiencing a medical condition or problem not previously documented in the medical history, select the Yes option next to the Do you have other conditions/problems not covered above? field and type the information in the field.

11. Type any additional information in the Enter Additional Comments Here field.

12. Select an option:

13. If you use an authorized electronic tablet and software to digitally capture a patient’s signature:Press Ctrl + Tab to make the Signature tab the active window.

14. If you do not user an authorized electronic tablet and software to digitally capture a patient’s signature:Skip to number 17.

13. Click Get Signature. A message asking you to print a Consumer Awareness statement is displayed.

14. Click the appropriate button and click OK. If you click Yes, the Output Options window is displayed. Select an option and click OK. The Digital Signature field is highlighted, and Acquiring Signature is displayed in flashing red text beneath the field, and the Get Signature button is replaced by the Done button.

15. Signatures acquired from the electronic signature capture device are stored in the PWImages folder located in the directory.

15. Instruct the patient to sign the electronic signature capture device. The signature is displayed in the Digital Signature field.

16. Click Done. The patient’s signature is captured as an image, and the Done button is replaced by the Get Signature button.

17. Click OK.

18. Click Close.