Patient History Tab - Injury

Use the Patient History > Injury tab to display a list of the injury and treatment records for the currently-selected patient, whose name appears above the tab. This information is primarily for reference; only one field (used to record the patient's reported level of pain) can be edited here. Use this tab to determine how many times a patient has come to the clinic for a specific injury and to view other treatment information. More detailed information about the injury and each treatment may be available from the Visit History tab.

Double clicking in any section of the grid takes you to the associated data entry screen, where information can be added or edited. After viewing a data entry screen, return to the CWA by using the Back button, the Ctrl+B key combination, or by selecting the Clinical Work Area tab at the bottom of the screen.


The Patient History/Injury tab

Label Description
Injury List Fields

Inj. ID

A unique number assigned to an injury. This number is automatically incremented on each new record added for the same injury.

Case Status

Indicates whether or not a case has been closed. Entries are Y or N.

Inj. Date

The date the injury occurred or, in the case of illness, the date of onset of symptoms.

Latest Trt

The date of the most recent treatment.

Physician Diag

The physician's diagnosis of injury.

Patient Desc

The patient's description of the incident.

Treatment List Fields

Treat Status

The Appointment status for the Treatment (A for Appointment, T if the Treatment has occurred, N for No show or C for Canceled).

Date

Date of Appointment or Treatment.

Time

Time of the Appointment or Treatment, entered in 24-hour time.

Treatment

Treatment/Appointment description.

Staff

Medical Staff person who worked with the patient.

Code

The Appointment code, which describes the type of visit.

Pain

The patient's estimate of pain level, measured on a scale from 0 to 10. Editable field; select an entry from the drop-down menu or type in data.

Notes

This field displays the first line of the F3 memo from the Treatment record. You may need to expand the field to read this information.

ID

A SYSTOC-assigned number to identify treatments; automatically increments with each new record. Same as the Treatment ID on the Treatment data screen.