Adding a Medical History Entry

To record a Medical History entry :

1. From Consultation Manager , select the patient required and start a consultation if required.
2. Select either:
   • Add - Medical History
   • Add Medical History from the tool bar, or
   • Use Alt+A then Alt+L if using the keyboard.
3. The History - Add screen displays:

   

   Complete as follows:

   • Event Date - Defaults to today's date, update as required.
   • Clinician - Defaults to the staff member or GP signed on for the current session, update as required.
   • Private - Defaults to unticked, tick if you are recording a private consultation.
   • In Practice - Ticked by default, remove tick to record result was recorded out of the practice.
     See Date, Clinician, In Practice/Private for further details.
   • Read Term for Characteristic - Find the clinical term required, see Finding a Read Code for details.
   • Comment - Optional, enter any free text comment required.
   • Type of Characteristic - Updates automatically based on the Read Term for Characteristic, update from the available list if required.
   • Episode Type - Defaults to Other, update from the available list if required.
   • Priority - Defaults to 3, update if required, see What is a Priority? for details.
     Note - You can update the defaults for Episode Type and Priority from the Consultation Manager set up screens, see Consultation Manager Setup - Data Entry for details.
   • End Date - Optional, you can enter a date if the patient's issue is resolved, or you can return to the entry at a later date and to complete it.
   • Recall - Select to add recall dates if required.
   • IOS - No longer used.
   • Another - Select to save the current entry and add another medical history.
     
4. Select OK to save.

If the term selected in Read Term for Characteristic links to a Structured Data Area (SDA) the SDA screen displays.

If the term selected in Read Term for Characteristic triggers a guideline, and the option to display guidelines after history entries is switched on, you are asked if you want to view it.

If you have semi-automatic problem generation switched on, you will be asked if you want to create a problem based on this Read term.