The History and Symptoms tab is designed to view, add, remove, and confirm a variety of categories regarding the patient's current health and health history.
Each section listed here directly correlates to the patient's pre check-in questionnaire, which they filled out prior to their appointment. The data here, once confirmed by a Nurse and Support staff member, becomes permanently part of that patient's records.
Nurse & Support Narrative and Symptoms
The Narrative section allows you to type or dictate any patient visit notes, while Symptoms displays any symptom the patient may be currently experiencing. Already provided for us, we see the note "From Patient." Likewise, under symptoms we see a symptom which is directly associated with their chief complaint and was generated for us when the appointment began.
We can input additional notes at this time. To add the narrative to the record and make them available for the Provider, click Save. Upon clicking Save, note also, how the symptoms list has been updated with the keywords provided in the narrative.
- You can change the value of a symptom by clicking on the Value (e.g., Yes will become No).
- To remove the symptom from the list first select the item, then click Remove.
- To add additional symptoms to the list click New.
Select or search for the symptom you are looking for, and click Save.
Clicking Save may open the Symptom Modifiers window. If you don't wish to add any symptom modifiers, just close the window.
The Medication section displays all medications associated with the patient's record. These medications can come from 3 sources:
- Medications can be fetched from SureScripts by clicking the Get from
- Medications that are previously confirmed and part of the patient's medical record.
(Not Shown) New medications obtained from the patient's pre check-in questionnaire.
- A pre-existing medication can be identified by seeing who it has been confirmed by. Here we see their name followed by the date of confirmation.
- To confirm a new and unconfirmed medication first select the item, then click Confirm. You can also update the confirmation to a pre-existing record using the same method.
- If a patient is no longer taking a listed medication, it can be removed by first selecting the item, then clicking Is Historical. Clicking Add Existing allows previously removed records to be added back to the chart.
- Finally, long lists of medications can be searched by using the filter found by clicking the Hide/Reveal arrow on the left.
Many of the functions in the Allergies section are similar to Medications.
- Existing allergies have been previously confirmed, where as, new allergies have not.
- To confirm a new allergy or to re-confirm an exiting entry, select the desired items and click Confirm.
- To create a new allergy click New and search for that allergy.
- To remove an item select it and click Remove.
Listed under this next section are all Current Problems listed in the patient's record. Any new problems added during pre check-in will be found unconfirmed.
- Click the item to access the Edit Current Problems window.
1. Associate the problem with an ICD10 code and enter any other necessary and pertinent information.
- Confirm the problem and click Save.
Surgical and Family Health History
These next two sections display any previous surgical procedures the patient has undergone and items pertaining to the family health history of that patient, respectively. Confirming, adding, and removing records here works similarly to previous sections.
The final section of the patient's History and Symptoms tab is Social History. Here records of the patient's relationship with Tobacco, Alcohol, and Drugs are listed. New records can be added and removed as seen in previous sections. Additionally, the Tobacco and Alcohol sections allow for more details to be added by clicking Add More Details.