Patient History Tab - Medical History
The Medical History tab provides a single convenient location where a patient's medical information can be viewed and/or updated. It is divided into sections that contain selected fields from the Vital Signs, Medications, Allergy/Condition, and Immunization data entry screens. Records are listed chronologically with the most recent on top, except in the Medications section, where active medications are listed first.
You can add a record to any of the sections of this screen by right-clicking in that section and responding Yes to the resulting system prompt. Double-clicking also takes you to the related data entry screen, where you can add and edit data. Use the Back button, Ctrl+B, or the Clinical Work Area tab at the bottom of the screen to return to the CWA. For more information about the individual sections of this screen, see the discussion of the regular data entry screen for that section.
You can enter data into or edit the contents of any white fields on this screen; single clicking places the cell in edit mode. Free text areas are available in the Medications and Allergy/Condition sections, where you can enter a patient narrative or list medications not dispensed by the clinic. Be sure to use the Ctrl+F10 key combination in free text areas to enter a time/date stamp prior to entering text. Otherwise, outdated information may look current.