About a Patient's Medical History

 

In MedicalDirector Clinical, 'History' refers to a patient's medical conditions, both active and inactive. Note also that whilst the data tab in the Clinical Window states Past History, this list can also include current, active conditions.

To view a patient's medical history select the Past History tab from the patient's Clinical Window.  See also Adding, Editing and Deleting History Items.

o       Each history item contains a value for year (the year in which the condition first occurred) and date (the date on which the patient informed you of the condition), a description of the item, a comment, and codes that flag the item for printing in summaries and as confidential. An unlimited number of items can be stored for each patient.

o       Data can be viewed by Year, Date, Condition, Side, Status, Summary, Confidential and Coded by clicking on the appropriate column heading, or by All Records, Active, Inactive or Summary items.

o       The Comment field displays comments for a selected item.

o       The Coded field indicates if the diagnosis was made by selecting from the DOCLE list of diagnosis.

o       When there is no significant past medical history to report, tick the associated check box to indicate this.

 

When viewing all records, inactive items are displayed in grey.