Patient History Tab - Injury
Use the
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.
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. |