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 saved into the Medical History section of the patient's health profile only when you sign the encounter. See Recording an encounter diagnosis.
1. Open the Health Profile from the patient's chart using one of the following methods:
In the patient dashboard view, click Start/Open > Health Profile.
In the patient summary, expand the desired health profile section.
From an encounter or letter template (see Adding health profile items to an encounter or letter template).
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.
Select from your diagnostic code library or enter as free text.
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 summary > Medical History section, click the gear icon ⚙️ in the header.
Then, select the Hide Records with Resolved status check box.
Select to indicate that the problem was in the past and resolved. It is automatically selected when you change the status to Resolved.
Enter a specific date of the onset.
Enter any additional information.
5. Select Additional Fields to expand the data entry form. Fill in the extra fields, using the below table.
📌 Note: When you create a new health data entry or when viewing an entry without any information in the Additional fields section, the section remains closed by default. If any of the additional fields are populated, this section auto-expands when you open the entry.
Fill in the additional fields, using the below table as reference
Enter a description of the problem.
Select a life stage.
Enter a date the problem was resolved.
💡 Tip: Entering dates for profile items is optional. You can enter partial dates, such as only the year, month and year (use the YYYY-MM format), or a life stage.
Select to identify the profile item as a risk. Items selected appear in the list of patient risk factors (see Viewing patient risk factors).
6. To fold this section select Hide Additional Fields.
7. Click Save. The new item is added to the list.
📌 Note: You can sort all added items by dragging and dropping them in the order you prefer. This reordering reflects in the summary view of the patient’s chart and applies only to the current user. For more information, see the video Sorting medical conditions in a patient's chart.
8. To view or edit details about an item, click it.
9. To delete an item, click the trash icon.
10. To view an item's history, click the history icon.
Updated December 20, 2022