Overview
Documenting a new patient's history, or a new complaint for an existing patient, is mostly comprised of reviewing information submitted by the patient via the kiosk and updating the notes to reflect aspects important to the case.
In Order to see the New Patient History the Reason for Encounter visit type has to be NP
Complaint Details
Review History starts with the patient's complaint(s) using details entered by the patient in the electronic intake. Also available in this window are:
- Second, third and fourth complaints
- Review of Systems
- Past Health History
- Family Health History
- Surgeries / Trauma
- Smoking Status
- Social History
- Medications
- Supplements
- Demographics
When you select a complaint, details appear on the right. Review what the patient entered and make notes, as required, to describe the case and establish the foundation of the treatment plan. Use the Edit Pencil at the end of each text field to select specific information or begin typing in any field to enter your own descriptions. For example, enter information about the onset of the complaint in the Details field. Use the Additional Information field to further explain anything complaint specific, such as a history of pain in this region.
If the patient has completed the Outcome Assessment, click the View button to review details. If they have not, click Add Outcome Assessment and work through the questions with the patient.
Continue through each field to either confirm, add, or remove data, depending on the experience with the patient.
Utilizing Outcome Assessments - https://help.healthcoretech.com/a/1266150-utilizing-outcome-assessments
The report format uses bullet points, which makes entering information quick and easy. It is not necessary to compose detailed sentences to create good documentation
If the patient has selected multiple complaints there are two additional options:
Delete This Complaint: Use this button to remove a complaint if it isn't a unique aspect that belongs in the review
Change to Primary Complaint: If you determine a complaint is primary, use this button to change it in the review hierarchy
Review of Symptoms
Past Health History
Family Health History
Surgeries/Trauma
Smoking Status
Social History
Scan results of Social History questions for items that are relative to the case.
Medications
Supplements
Demographics
Complete the History
When you finish reviewing the patient history, click Complete. If you haven't indicated you reviewed the Informed Consent with the patient, a box will pop up to confirm.
Summary
Once Case History is completed the summary screen will show Current Complaints
Once Case History is completed click on the 3 lines to open the menu and click on Case History to see the History
Report
