Add Patient’s Medical History

1. The user can add a patient's medical history by accessing the Patients List Screen from two entry points.
   1. From the EMR Board Tabs, select “Patients.”
      
   2. From the Left Navigation, click on the “EMR Board” dropdown menu and select “Patients.” Alternatively, you can type “Patients” into the search bar in the Left Navigation.
2. Click anywhere on the patient's data in the patient listing, or click the three dots under the action column next to the specific patient and select “View Patient Profile.”
   
3. On the Patient Information Screen, users can access a comprehensive summary of all patient’s information. To view medical history, simply click on the “Medical History” tab.
   
4. The Medical History Screen will include sections for Social History, Allergies, Medications, Medical Conditions, Family History, and Past Medical. Click on “Edit” next to the sections you want to fill out.Note: The Medical History section also includes a Good Faith Exam (GFE) section and a Patient Vitals section. If a patient has completed a GFE, it will be displayed here. You can also record the patient’s vitals from this section by clicking the “Record Vitals Now” button.
5. Add Patient’s Social History
   1. Click “Edit” next to Social History to add details.
   2. If you select “Yes” for alcohol use, enter the drinks per week and add any notes.
      
   3. If “Yes” is selected for tobacco or exercise, enter the weekly frequency and any notes.
   4. Enter Current and Targeted Weight, add Notes, and click “Update Social History.”
      
      The patient’s social history has been successfully added!
6. Add Patient’s Allergies Information
   1. Click “Edit” next to Allergies Information to add details.
   2. "If “Yes” is selected for drug allergies, click the “+ Add Drug Allergy” button to enter details.
      
   3. Enter the Medication, then choose the Reaction and Allergy Type from the dropdown menus.
      
   4. Fill in the RxNorm, Onset and End Dates, and Comments, then click “Save Allergy."
      
   5. Follow the same steps to complete the Food and Environmental Allergies, then click “Update Allergies” to save your changes.
      The patient's allergies information has been added successfully!
7. Add Patient’s Medications
   1. Click “Edit” next to Current Medications to add details.
   2. "If “Yes” is selected for prescription medications, click the “+ Add Medications” button to enter details.
      
   3. Enter the Medication Name, Dosage, Frequency, Start and End Dates, and the NDC Code.
      
   4. Follow the same steps to complete the Vitamins & Supplements and Over the Counter Medications, then click “Update Medications” to save your changes.
      The patient’s medications have been added successfully!
8. Add Patient’s Medical Conditions
   1. Click “Edit” next to Current Medical Conditions to add details.
   2. "If “Yes” is selected for ongoing medical conditions or diagnosis, click the “+ Add Condition/Diagnosis” button to enter details.
      
   3. Enter the Condition/Diagnosis Type, Date of Diagnosis, and Name of Treating Physician.
      
   4. "If “Yes” is selected for dietary consideration, click the “+Add Consideration” button to enter details.
   5. Enter the considerations in the given field.
   6. Next, complete the pregnancy-related questions. If the patient is pregnant, select the Current Trimester, enter the Expected Due Date, and provide the number of previous pregnancies.
      
   7. Enter any additional pregnancy notes, then click “Update Current Medical Conditions” to save your changes.
      The patient’s medical conditions have been added successfully!
9. Add Patient’s Family History
   1. Click “Edit” next to Family Health History to add details.
   2. Click on “+Add Medical Issue” to enter and save the relevant details of the patient’s family medical issue.
   3. Enter the Diagnosis, specify the Relationship to the Patient, and add any relevant Notes if applicable. Once all information is completed, click “Update Family Health History” to save the details.
      
      The patient’s family health history has been added successfully!
10. Add Patient’s Past Medical & Surgical History
    1. Click “Edit” next to Past Medical & Surgical History to add details.
    2. "If “Yes” is selected for surgeries, click the “+Add Surgery” button to enter details.
    3. Enter the Surgery Type, Date of Surgery, Physician, City, State, and any relevant Notes.
       
    4. "If “Yes” is selected for hospitalization, click the “+Add Hospitalization” button to enter details.
    5. Enter the Reason for Hospitalization, Date of Hospitalization, Hospital Name, and any relevant Notes.
       
    6. "If “Yes” is selected for implants, click the “+Add Implants” button to enter details.
    7. Enter the Date of Implant, Type of Implant, Implant Details, and any relevant Notes.
       
    8. "If “Yes” is selected for vaccines, click the “+Add Vaccines” button to enter details.
    9. Enter the Vaccine Name, Date of Vaccination, and any relevant Notes. Once all information is complete, click “Update Past Medical & Surgical History” to save.
       
       The patient’s past medical & surgical history has been added successfully!

Edit Patient’s Medical History

11. On the Patient Information Screen, click on the "Medical History" tab. The Medical History Screen will display all the information already added.
12. Click on “Edit” next to the sections you want to edit.
13. Make the desired changes and click on “Update Medical History” once you’re done.
    The patient’s medical history has been edited successfully!