History is a comprehensive statement of facts pertaining to the past and present health information gathered from the patient. Patient’s history details are printed on the Encounter note.

 

Following are 2 sections where you can record the patient’s history details in the system: Patient Demographics and Charting.

 

Accessing History From Patient Demographics

From the left side, select the Patients tab and then click the History link. Click any patient name link. The History screen appears, or
From the top menu bar, click Patient Search. Click the clip0002icon corresponding to the patient name and click the History tab.

 

Accessing History From Charting

From the left side, select the Charting tab and then click the History link. Click any patient name link. The Facesheet screen appears. Start a new encounter by clicking the Start Encounter button and then click the History link from the top, or
From the top, click Patient Search. Click Facesheet corresponding to the patient name. The Facesheet screen appears. Start new encounter by clicking the Start Encounter button and then click the History link from the top.

 

History is categorized as follows:

General Notes
Social History
Medical History
Psychiatric History
Family History
Surgical History
Gynecological History
Genetic History
Summary

 

If the patient’s history details are already recorded in the system, the Summary tab opens by default in the left side, otherwise the Social History tab opens to record the necessary information.

    See also,

  Summary