History is a comprehensive statement of facts pertaining to the past and present health information gathered from the patient. Patient’s history details are printed on the Encounter note.
Don't forget:
If the patient’s history details are already recorded in the system, the Summary tab opens by default, otherwise the Social History tab opens to record the necessary information.
Recording patient’s history 2 ways:
Accessing History From Patient Demographics
| • | From the left side, select the Patients tab and then click the History link. Click any patient name link. The History screen appears, or |
| • | From the left menu, click Patient Search. Click the  icon corresponding to the patient name and click the History tab. |
Accessing History From Charting
| • | From the left side, select the Charting tab and then click the History link. Click any patient name link. The Facesheet screen appears. Start a new encounter by clicking the Start Encounter button and then click the History link from the top, or |
| • | From the left menu, click Patient Search. Click Facesheet corresponding to the patient name. The Facesheet screen appears. Start new encounter by clicking the Start Encounter button and then click the History link from the top. |
History is categorized as follows:
Let's see how we can add history details:
Adding General Notes
This section helps practices to record general notes about patient's history.
To record general Notes:
| 1. | On the History screen, click General Notes tab on the left side. |
| 2. | In the General Notes field, enter any general notes pertaining to patient’s history record. |
| 3. | To add general notes using macros, click the  icon. |
| 4. | Click Save and notes will be saved. |
Adding Social History
This section helps practices to record patient's social history.
To record patient's Social History:
| 1. | On the History screen, click the Social History tab on that appears on the top to record the patient’s social history elements. These elements are configurable in the system. They can be patient’s living environment, physical activity, social behavior, and so forth. The user can choose multiple options for each social history element when recording them. The configuration is explained in the Administration section of this manual. |
| 2. | If patient does not know or denies to disclose social history, select the No Known Social History check box. |
| Note: Once the ‘No Known Social History’ check box is selected, system disables the ‘Patient is non-smoker’ option on the Meaningful Use 1 Reminder(s) screen. |
| 3. | Under Consumption enter details such as patient’s smoking habits, alcohol frequency, and caffeine usage and click the add button to insert the record. The Consumption details you record will appear in the drid below. |
| 4. | In the Social History Notes box, enter the notes pertaining to patient’s social history details. |
| 5. | In the Confidential Notes box, enter confidential details about patient’s social history. Being confidential notes, they are displayed only to that provider and also not printed on the Encounter note. |
| 6. | Click Save and Social History details will be saved. |
Key points to know while Recording Social History
| • | For patients who are 13 years or older, record the smoking status. If the patient is a nonsmoker, select the Patient is non-smoker check box. This will help in increasing the numerator for “Core 5: Record smoking status for patients 13 years or older” of MU-2. Please refer to the above section in Meaningful Use Stage – 2 User Guide for more details. |
| • | Click the Delete icon  to delete the selected record. |
| • | When “Social History” section is accessed from Facesheet, the “Consumption” section name is displayed as “Consumption/Diet”. A new section “Glucose/Others” appears above the Social History Notes box. Under Glucose/Others, record the glucose or blood pressure level and provide comments, if any, and click the add button to insert the record. |
Adding Medical History
This section helps practices to record patient's medical history. It is divided into two sections; Medical History and Medical History (Ob/Gyn). The Medical History (Ob/Gyn) section is further divided into two sections; Medical and Infections History.
Note: The Gynecological History tab is visible in the system only for female patients.
To record patient's medical history:
| 1. | On the History screen, click the Medical History tab on the left side to record the patient’s medical history records. |
| 2. | If patient does not know or denies disclosing medical history, select the No Known Medical History check box. |
| 3. | In the Medical History section: |
| • | Enter the illness in the Illness field, |
| • | Enter the Age of when the illness was identified. |
| • | Select the illness Status from the drop-down list, |
| • | Enter the duration the patient has had this illness, |
| • | Enter the treatment the patient has undergone for this illness, if any, and |
| • | Click the add button to insert the record |
| 4. | In the Medical History Notes field, enter any notes pertaining to patient’s medical history record. |
| 5. | In the Medical History (Ob/Gyn) section: |
| • | Select appropriate options to record patient's medical history. |
| • | To enter notes specific to any element of medical history, enter the notes in the text box provided next to that element. |
| • | Enter Medical History Notes, if any. |
| • | In the Infections History section, select appropriate options to record patient's infection history. |
| • | To enter notes specific to any element of infection history, enter the notes in the text box provided next to that element. |
| • | Enter Infection History Notes, if any. |
| 6. | Click Save & Next. The Psychiatric History screen is displayed. |
Key points to know while Recording medical history
| • | Click the Delete icon to delete the selected record. |
| • | The Date column on the left side in the grid only appears if the History section is opened from the Charting section. It is basically to capture the visit date during which the history details were recorded in the system. It will not appear if the History section is opened from the Patient Demographics section. |
Adding Psychiatric History
This section helps practices to record patient's psychiatric history.
To record patient's psychiatric history:
1. On the History screen, click the Psychiatric History tab on the top to record the patient’s psychiatric history records.
2. If patient does not know or denies disclosing psychiatric history, select the No Known Psychiatric History check box.
3. Enter the psychiatric illness in the Illness field.
4. Select the Illness Status from the drop-down list.
5. Enter the duration the patient has had this illness.
6. Enter the treatment the patient has undergone for this illness, if any.
7. Click the add button to insert the record.
8. In the Psychiatric History Notes field, enter any notes pertaining to patient’s psychiatric history record.
9. Click Save to save psychiatric notes.
Key points to know while Recording psychiatric history
| • | Click the Delete icon to delete the selected record. |
| • | The Date column on the left side in the grid only appears if the History section is opened from the Charting section. It is basically to capture the visit date during which the history details were recorded in the system. It will not appear if the History section is opened from the Patient Demographics section. |
Adding Family History
This section helps practices to record patient's family history.
To record patient's family history:
| 1. | On the History screen, click Family History tab on the top to record the patient’s family history details. |
| 2. | If patient does not know or denies to disclose family history, select the No Known Family History check box. |
| 3. | In the Family History tab, select from the drop-down list the patient’s relationship with the family member whose details you want to record. |
| 4. | Select the existing status of the family member, living or deceased, from the drop-down list. |
| 5. | Enter the age of the living family member. |
| 6. | Enter the illness the patient’s family member has, if any. |
| 7. | Enter the note specific to the illness. |
| 8. | Click the add button to insert the record. |
| 9. | In the Family History Notes field, enter any other details pertaining to patient’s family, if any. |
| 10. | Click Save to save family history. |
Key points to know while Recording family history
| • | Click the Delete icon to delete the selected record. |
| • | The Date column on the left most side in the grid only appears if the History section is opened from the Charting section. It is basically to capture the visit date during which the history details were recorded in the system. It will not appear if the History section is opened from the Patient Demographics section. |
Adding Surgical History
This section helps practices to record patient's surgical history.
To record patient's surgical history:
| 1. | On the History screen, click the Surgical History tab on the top to record the patient’s surgical history details. |
| 2. | If patient does not know or denies disclosing surgical history, select the No Known Surgical History check box. |
| 3. | In the Surgical History tab, enter the name of the surgery performed on the patient. |
| 4. | Enter the date on which the surgery was performed or select the date from the calendar icon. |
| 5. | Enter the facility name where the surgery was performed. |
| 6. | Enter the provider name that performed the surgery. |
| 7. | Enter the outcome of the surgery. |
| 8. | Enter the notes pertaining to the surgery. |
| 9. | Click the add button to insert the record. |
| 10. | In the Surgical History Notes box, enter notes pertaining to surgical history, if any. |
| 11. | Click Save to save surgical history. |
Key points to know while Recording surgical history
| • | Click the Delete icon to delete the selected record. |
| • | The Date column on the left most side in the grid only appears if the History section is opened from the Charting section. It is basically to capture the visit date during which the history details were recorded in the system. It will not appear if the History section is opened from the Patient Demographics section. |
Adding Gynecological History
This section helps practices to record patient's gynecological history.
To record patient's Gynecological History:
| 1. | On the History screen, click the Gynecological History tab on the top to record the patient’s gynecological history details. |
Note: The Gynecological History tab is visible in the system only for female patients.
| • | In the Menstrual History section, enter the necessary details to record patient's menstrual history. |
Note: The menstrual history details that appear in the grid are from the past encounters.
| • | Enter the Age of Menarche. |
| • | Enter the Last Menstrual Period, |
| • | Select an appropriate option (Definite, approximate or unknown )/ |
| • | Enter the Frequency Q days. |
| • | Enter duration and flow amount. |
| • | Click the switch to indicate BCP intake. |
| • | Click the switch if menopause has occurred and enter the Age of Menopause. |
| • | In the Obstetric History section, enter the number of total pregnancies, full term, pre-term, AB induced, AB spontaneous, living, ectopics, and multiple births. |
Note: The Full Term, Pre Term, AB Induced, AB Spontaneous, Living, Ectopics, and Multiple Births should not exceed the total number of pregnancies.
| • | In the Past Pregnancies section, add the details of past pregnancies entering Delivery Date, GA (Weeks), Preterm Labor, and so on. |
Note: The number of past pregnancies should not exceed the number of total pregnancies.
2. Click Save and the Gynecological details will be saved.
Key points to know while Recording Gynecological History
| • | Click the Delete icon to delete the selected record. |
| • | The Date column on the left most side in the grid only appears if the History section is opened from the Charting section. It is basically to capture the visit date during which the history details were recorded in the system. It will not appear if the History section is opened from the Patient Demographics section. |
Adding Genetic History
This section allows recording patient’s genetic history. This section is accessible from two places; History module and Antepartum Form.
Note: The Gynecological History tab is visible in the system only for female patients.
To record patient's genetic history:
| 1. | On the History screen, click the Genetic History tab on the top to record the patient’s genetic history details. |
| 2. | If patient does not know or denies to disclose genetic history, select the No Known Genetic History check box. |
| 3. | In the Genetic History section, select appropriate options to record patient's genetic history. |
| 4. | To enter notes specific to any element of genetic history, click on this  icon. |
| 5. | Enter Comments, if any. |
| 6. | Click Save to record genetic history details. |
Summary
The Summary tab shows the details recorded in the history elements above. Once you review the summarized history details, you can select the Reviewed by check box from top left corner and select date and time of review. You can also print the history information from the Summary tab.
Note: The Reviewed by check box will only appear if the History section is opened from the Charting section. It will not appear if the History section is opened from the Patient Demographics section.
