Record the Medical History

  1. Go to Inj/Ill Visit screen (click button or press Alt+J).
  2. Click Medical History/Vitals (Alt+Y), take vitals and enter on screen, Save (Ctrl+S).
    Optionally, you can use the PDF form attached to the order for data entry.
  3. If patient has unlisted allergies or chronic conditions, double-click anywhere in Allergies area to access form and Add (Ctrl+A), Save (Ctrl+S), Back (Ctrl+B). Add NKA record if No Known Allergies. Adjacent text field can be used to enter patient’s description of allergy condition.
  4. Verify the medications. If patient is on any medications not listed, double-click on Medications area and complete as in step above. To change the active/inactive status of any medication, click on Active box, Save. Adjacent text field can be used to enter patient’s description of medication s/he is currently taking.
  5. Return to Inj/Ill Visit screen with Back button (Ctrl+B) or click tab at bottom of screen.
  6. For security, before leaving patient alone in exam room, press F11 to minimize SYSTOC and log out.
  7. If your work flow is not “paperless,” record medical history on paper and enter later via Orders, via the Medical History button on the Appointment Register screen, or via the menu choices that appear under Patient Folder.