Medical History

This screen combines selected fields from the Injuries, Allergies/Conditions, Vital Signs, Medications and Immunization screens to provide a single convenient location where patient medical information can be viewed and/or updated. Records are listed chronologically with the most recent on top except for Medications, where active medications are listed first.

Access via the Appointment Register > Med History button, or Medical History > Vitals button on the Inj/Ill Visit screen, or Patient Folder > Medical History, or Clinical Work Area > Patient History tab > Medical History tab.

Right-click in the appropriate section to add a new record. Single click on white areas to edit/enter free text. Double click on any other area to go to the data screen. For more information about the columns in any section of this screen, please see this manual's discussion of the regular data screen view for that section.

Make adjustments as you reviews current medications with the patient. Make a medication active or inactive by clicking on the Active column. If the patient is not on any medications, add a record with NKMED as the Medication ID . If the patient is on a drug that is not in your available medications list, use the white box to type whatever the patient tells you about drugs prescribed elsewhere. If you use this approach, be sure to stamp the entry with the date/time/user by pressing Ctrl+F10.

Indicate that you asked about allergies by adding a record with NKA (no known allergies) as the Allergy/Condition ID. The free text box in the allergies/conditions section can be used to enter additional information, but be sure there is an Allergy/Condition ID for each chronic problem the patient reports.

If there is an allergy record other than NKA or None, SYSTOC will provide an alert. The alert consists of an image of a red stop sign with a white hand and a red plus sign. The alert appears on the Medical History screen accessed from the Medical History menu option in the Patient Folder and in several places in the Clinical Work Area. It will flash once when a new allergy is added. You can turn the alert off, by checking the field Suppress Allergy Alert. The button labeled Alert Med History can be used as a way to jump to the Medical History tab from any other tab in the CWA.

When upgrading from earlier versions, SYSTOC will automatically check the Suppress Allergy Alert if NKA, None, No Known Allergies, No allergies, or Unknown are found as entries. While this may help to prevent alerts that are unnecessary, it also can mean that the alert may not be appropriately set in all circumstances. Users are advised to review historical data and make corrections as needed.

Note: Users will need to manually uncheck the Suppress Allergy Alert and remove the old NKA record (or memo) if they add an allergy for a patient who previously was registered with NKA or None.

Note: If you leave the Medical History form to go to specific data screen components, you may need to use the Reload button to redraw the screen when you return.

Medical History Field Descriptions

Label	Description
Last Tetanus	The date of the patient's last tetanus immunization. The system checks this field when the form is saved, and will display a warning message if the date is more than 5 years in the past.
Injuries	This section lists a few details about previous injuries, most recent on top. Double-clicking in this section takes you to the related Injury screen.
Allergies/Conditions	This section lists current allergies and/or conditions. To indicate that you asked the patient about allergies, use `NKA` for no known allergies. The white box can be used to enter free-text description of an allergy or condition. Adding a record other than `NKA` activates an allergy alert, that can be suppressed if desired. If you use the box, be sure to add your user ID, date and time by pressing Ctrl+F10.
Vitals	The fields are self-explanatory. A new blank record is created on the day of the patient's appointment for use in collecting current information.
Medications	This section lists current and past medications. Current medications will be on top, with a check mark in the Active box. To mark a medication inactive, remove the check mark. The white box can be used to enter vague descriptions of medicines the patient reports taking. Be sure to enter your initials, date, and time (using Ctrl+F10) if you make an entry in the white text box.
Immunization History	This section lists immunizations. Double-click to view any particular item, or right click to add a new one.
Problem List	The problem list provides the provider with a brief list of a patient's ongoing medical conditions. Double-click to view any particular item. See also Problem List.
1st and 2nd Alternate IDs	Used to cross reference the Patient ID with IDs from other systems, or as an ID number for privacy cases. The 1st Alternate ID also appears on the Patient Summary screen.