Medical History

Medical History

To add information to the patient's Medical History, follow the steps below and do not forget to complete the required fields (*).

 

Problem List

• Problem List: To add a Patient's Problem, click the first icon on the right and then click “+ New Problem List".

• Complete the Patient's Problem. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.

• (*) Health Problem: Select Patient's Health Problem from the look up list (click   or press Enter).
• Severity:  Severe, Moderate y Mild.
• Body Site: Select Problem's Body Site from the look up list (click  or press Enter).
• Complication: Select Problem's Complication from the look up list (click  or press Enter).
• (*) Clinical Status: Select Problem's Clinical Status from these values: Active, Inactive, Recurrence, Remission or Resolved.
• Onset Date: Enter Problem's Onset Date.  If the "Onset Date" is greater than today an error will be displayed  .
• Context Type: Select Problem's Context Type from these values: Encounter or Episode Of Care.
• Description: Enter Problem's Description.
• Click “Save and Close”.

Open the created record.
To access Medical History Information, select the record and click “Edit”.


Click
 

• Problem Stages: To add a Problem Stage, click “+ New Problem Stage".

• Complete the Problem's Stage. Fields with (*) are required fields and must be completed before save the record.
  • • (*) Summary: Select Problem Stage's Summary from the look up list (click  or press Enter)
    • (*) Type: Select Problem Stage's Type from the look up list (click  or press Enter)
  • Click “Click “Save and Close”.”

 

Medication List

• Medication List: To add a Patient's Medications, click the second icon on the right and then click " + New Medication List".

Complete the Patient's Medication. Fields with (*) are required fields and must be completed before save the record.
 

• Self-Reported: Select from values: Yes or No.
• (*) Medication Reference: Select Patient's Medication from the look up list (click  or press Enter).
• (*) Medication Status: Select Medication Status from these values: Active, Cancel Denied, Cancel Pending, Cancel Requested, Cancelled, Changed, Completed, Deleted or Discontinued.
• Medication Type: Select Medication's Type from these values: Generic RX or Brand Name. This field will be hide if the “Self-Reported” value is Yes.
• Effective Date Time: Enter Medication's Effective Date Time. This field will be hide if the “Self-Reported” value is Yes.
• Quantity Dosage: Enter Medication's Quantity Dosage.
• Unit: Select Medication's Unit from the look up list (click  or press Enter).
• Frequency: Select Medication's Frequency from these values: Every day, Twice a day, Three time a day or Four times a day. This field will be hide if the “Self-Reported” value is Yes.
• Dose: Enter Medication’s Dose.
• Days’ Supply: Enter Medication's Days' Supply.
• (-) Form: This field will be autocompleted after the "Medication Reference" is selected.
• (-) Medication Route: This field will be autocompleted after the "Medication Reference" is selected.
• Description: Enter Medication's Description.
• Written Date: Enter Medication's Written Date. If the "Written Date" is greater than today an error will be displayed 
• Inactive Date: Enter Medication's Inactive Date. If the "Inactive Date" is greater than today an error will be displayed.
  • Click “Save and Close”.

 

Preferred Medications

• Preferred Medication: To add a Patient's Preferred Medication, click the third icon on the right and then click “+ New Preferred Drug List".

 

• Complete the Patient's Preferred Medication. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Medication: Select Patient's Medication from the look up list (click  or press Enter).
  • Quantity Dosage: Enter Medication's Quantity Dosage.
  • Unit: Select Medication's Unit from the look up list (click  or press Enter).
  • Frequency: Select Medication's Frequency from these values: Every day, Twice a day, Three time a day or Four times a day.
  • Dose: Enter Medication’s Dose.
  • Period (days): Enter Period Days'.
  • Medication Status: Select the Medication Status from these values: Active, Cancel Denied, Cancel Pending, Cancel Requested, Cancelled, Changed, Completed, Deleted, Discontinued, Prescribed.
  • Effective Date Time: Select the Date.
  • Click “Save and Close”.

 

Allergies

• Allergies: To add a Patient's Allergy, click the fourth icon on the right and then click “+ New Allergy".

• Complete the Patient's Allergy. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.

• (*) Allergy: Select Patient's Allergy Intolerance from the look up list (click  or press Enter)
• (*) Allergy Date: Enter Allergy Date.  If the "Onset Date" is greater than today an error will be displayed 

• (*) Verification Status: Select Verification Status from these values: Active, Inactive or Deleted
• (*) Reaction: Enter Reaction. 
• (*) Reaction Type: Select Reaction Type from these values: Allergy or Adverse Reaction
• (*) Critically: Select Critically from these values: Low Risk, High Risk or Unable to Assess Risk
  • Click “Save and Close”.

 

Family History

• Family History: To add a Patient's Family History, click the fifth icon on the right and then click " + New Family History".

• Complete the Patient's Family Member. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Family Member: Select Patient's Family Member from the look up list (click  or press Enter). If the family member does not exist, you can create a new one of type Potential Patient following the next steps:
    • • • Click “+ New Contact”.

• • • • • Then in the Contact Type field, click “Potential Patient” and fill out all fields, remember that fields with (*) are required fields and must be completed before save the record.

   

• • (*) Relative: Select Relative from these values: Father, Mother or Sibling.
  • Age.
  • Deceased: Select Deceased from these values: Yes or No.
  • If you select Yes, complete: Deceased Date and Cause of death.
  • Family Status: Select the Family Status.
    • • Click “Save and Close”.

Open the saved record.
To access Medical History Information, select the record and click “Edit”.

• Problem List: To add Family Member's Problem List, click  and then " + New Problem List".

• • Complete the Family Member's Problem List. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
    • (*) Health Problem: Select Family Member's Health Problem from the look up list (click  or press Enter).
    • Severity: Select Problem's Severity from these values: Mild, Moderate or Severe.
    • Body Site: Select Problem's Body Site from the look up list (click  or press Enter).
    • Complication: Select Problem’s Complication from the look up list (click  or press Enter).
    • ClinicalStatus: Select Problem's Clinical Status from these values: Active, Inactive, Recurrence, Remission or Resolved.
    • Onset Date: Enter Problem's Onset Date.
    • Context Type: Select Problem's Context Date from these values: Encounter or Episode of Care.
    • Description: Select Problem's Description.

 

Immunizations

• Immunizations: To add a Patient's Immunization, click the sixth icon on the right and then click " + New Immunization List".

• Complete the Patient's Immunization. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Vaccine: Select Patient's Vaccine from the look up list (click  or press Enter).
  • Primary Source: Select Immunization's Primary Source from these values: Yes or No.
  • (*) Immunization Status: Select Immunization's Status from these values: Completed, Entered in Error or Not Done.
  • Occurrence: Entered Immunization's Occurrence Date.
  • Report Origin: If the value of the "Primary Source" us "Yes" this field will be displayed. Select Immunization's Report Origin from these values: Other Provider, Written Record, Parent/Guard/Patient Recall or School Record.
  • Site: If the value of the "Primary Source" us "Yes" this field will be displayed. Select Immunization's Site from these values: Nasal or Left Arm or Right Arm.
  • Quantity (mL): If the value of the "Primary Source" us "Yes" this field will be displayed. Enter Immunization's Dose Quantity.
  • Performed: If the value of the "Primary Source" us "Yes" this field will be displayed. Select Immunization's Performed from the look up list (click  or press Enter).
  • Lot Number: If the value of the "Primary Source" us "Yes" this field will be displayed. Enter the Vaccine Lot Number.
  • Expiration Date: If the value of the "Primary Source" us "Yes" this field will be displayed. Enter the Vaccine Expiration Date.
  • Click “Save and Close”.

To create Immunization Reactions

• Open the saved record.

 

• Then click  Reactions: To add an Immunization's Reactions, click “+ New Immunization Reactions."

• • Complete the Immunization Reactions. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
    • (*) Date: Enter Immunization Reaction Date.
    • (*) Detail: Enter Immunization Reaction Detail.
    • Reported: Select from these values: Yes or No.
    • Click “Save and Close”.

 

Functional Status List

• Functional Status List: To add a Patient's Functional Status, click the seventh icon on the right and then click " + New Functional Status List".

• Complete the Patient's Functional Status. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.

• (*) Functional Status (SNOMED Code by Description): Enter Patient's Functional Status.
• Observation Date. Enter Observation Date. If the "Observation Date" is greater than today an error will be displayed   .
• Click “Save and Close”.

 

Mental Status List

• Mental Status List: To add a Patient's Mental Status, click the eighth icon on the right and then click “+ New Mental Status List".

• Complete the Patient's Mental Status. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Mental Status (SNOMED Code by Description): Enter Patient's Mental Status.
  • Effective Date. Enter Effective Date. If the "Effective Date" is greater than today an error will be displayed  .
  • Click “Save and Close”.

Devices

• Devices: To add a Patient's Device, click on the last icon on the right and then click “+ New Device".

• Complete the Patient's Device. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) UDI: Enter Patient's Device UDI. After the UDI is filled all the Device fields will automatically completed. For example:
    • (01)10884521062856(11)141231(17)150707(10)A213B1(21)1234
    • =/08717648200274=,000025=A99971312345600=>014032=}013032&,1000000000000XYZ123
    • =/A9999XYZ100T0944=,000025=A99971312345600=>014032=}013032&,1000000000000XYZ123
    • +H123PARTNO1234567890120/$$420020216LOT123456789012345/SXYZ456789012345678/16D20130202C
    • Click “Save and Close”.

                            If you have DoctorHelper’s app installed in your cellphone, click on

  

The barcode will be completed in the UDI field

• • (-) Patient: This field will be autocompleted.
  • Location: Select Device Location from the lookup list (click  or press Enter)
  • (-) Expiration Date: This field will be autocompleted.
  • (-) Version or Model: This field will be autocompleted.
  • (-) HCT/P: This field will be autocompleted.
  • (-) What MRI safety infor. does the labeling contain? This field will be autocompleted.
  • (-) Device Identifier: This field will be autocompleted.
  • (-) Device Manufacturing Date: This field will be autocompleted.
  • (-) Company Name: This field will be autocompleted.
  • (-) Serial Number: This field will be autocompleted.
  • (-) Lot Number: This field will be autocompleted.
  • (-) Brand Name: This field will be autocompleted.
  • (-) Device Description: This field will be autocompleted.
  • (-) Device required to be labeled as containing natural rubber latex or dry natural rubber: This field will be autocompleted.
  • (-) SNOMED CT Description: This field will be autocompleted.
  • (-) MPHO Lot Number: This field will be autocompleted.
  • (-) Donation Identification Number: This field will be autocompleted.
  • Device Status: Select device status from these values: Active, Inactive, Unknown, Entered-in-error.

Procedures

To create the Patient’s Procedures, click the tab “Procedures” and follow the steps below:


 

Procedures & Diagnostic Images

• Procedures & Diagnostic Images: To add a Patient's Procedures and Diagnostic Images, click “+ New Procedure List”.

 

• Complete the Patient's Procedure. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Medical Procedure: Select Patient's Medical Procedure from the look up list (click  or press Enter)
  • Ordered By: Click  and look for Ordered By
  • (*) Procedure Date: Select the Procedure Date
  • (*) Order Status: Select Procedure's Order Status from these values: Pending, Canceled or Completed
  • Description: Enter Procedure's Description
  • Click “Save and Close”.

 

Laboratory Order List

• Lab Orders List: To add a Patient's Laboratory Order, click “+ New Lab Order List"

• Complete the Patient's Laboratory Order. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Lab Order: Select Patient's Laboratory Order from the look up list (click  or press Enter).
  • Date: Enter Lab Order's Date.  
  • Performed: Enter Laboratory Name
  • Order Status: Select Lab Order's Order Status from these values:  Pending, Canceled or Completed
  • Description: Enter Lab Order's Description
  • Click “Save and Close”.

 

Pending Internal Procedures

• Pending Internal Procedures: Here you can find all the procedures that the patient has pending to be performed within the same clinic. This information is created during the appointment process.

 

Completed Internal Procedures

• Completed Internal Procedures: Here you can find all the internal procedures completed within the same clinic. This information is created during the appointment process.