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 A coding system used to standardise data entry, help ensure consistency, and provide a base for use with Drug Interactions and Searching 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.