The Medical History section of the health profile enables you to record the patient's medical conditions and ongoing health problems.

⚠️ Important: Diagnoses entered in the Assessment and Plan section of an encounter are save into the Medical History section of the patient's health profile only when you sign the encounter and you select Update this patient's medical history from diagnoses in the window that appears.

Steps

1. Open the health profile from the patient's chart using one of the following methods:

2. Expand the Medical History profile section.

3. To add a new item, click the +.

4. Fill in the fields, using the following table as reference.

Field

Description

Diagnoses

Select from your diagnostic code library or enter as free text.

Status

Specify the status (such as active or in remission).

By marking problems as resolved, you can then hide them when viewing the list of problems in the patient summary.

To access this setting, in the patient symmary > Medical History section, click the gear icon ⚙️ in the header.

Then, select the Hide Records with Resolved status check box.

Past

Select to indicate that the problem was in the past and resolved. It is automatically selected when you change the status to Resolved.

Description

Enter a description of the problem.

Life stage / Onset date / Resolution date

Enter a life stage or specific date of the onset and resolution of the problem.

💡 Tip: Entering dates for profile items is optional. You can enter partial dates, such as only the year, month and year, or a life stage.

Risk factor

Select to identify the profile item as a risk. Items selected appear in the list of patient risk factors (see Viewing patient risk factors).

Notes

Enter any additional information.

5. Click Save. The new item is added to the list.

6. To view or edit details about an item, click it.

7. To delete an item, click the trash icon.

8. To view an item's history, click the history icon.

Updated May 31, 2021

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