Adding Medical History

How to add, edit, resolve, and delete a patient's medical history

Updated over a week ago

Adding to a Patient's Medical History

To add to a patient's medical history, navigate to the patient's Profile tab and click on the New button in the Medication History panel.

A new Medical History entry field will appear with a smart search drop down of SNOMED diagnoses that you can select from. You can also enter your own custom diagnosis in this field.

🌟TIP: For quicker entry of medical history data, press the "Tab" key to automatically add a new medical history entry field.

To add additional details to a medical history diagnosis, click on the info icon beside a medical history entry.

This will launch the Edit Medical History dialogue. Here you can:

  • Favourite a frequently-diagnosed condition by clicking on the star icon to the right of the diagnosis text field.

  • Add an ICD-9 code for your diagnosis, by either manually typing the code if known or selecting a code from the ICD-9 smart search dropdown.

  • Favourite a frequently-used ICD-9 code by clicking on the star icon on the right of the ICD-9 code field.

  • Add comments to your diagnosis.

🌟TIP: ICD-9 codes that are starred for billing (by clicking on the billing icon on the right of the ICD-9 code text field) will auto populate as the patient's ICD-9 code when you create a new billing.

Resolving a Patient's Medical History

You can resolve a condition in the patient's Medical History panel by checking off the circle located on the left of a diagnosis. Doing so will mark the diagnosis as "Inactive".

You can view a patient's inactive medical history by clicking on the Show Inactive button at the bottom of the Medical History panel.

Deleting a Patient's Medical History

To delete an entry from a patient's medical history:

1. Click on the Edit button in the Medical History panel.

2. Click the Delete icon on the right of the diagnosis that you want to delete.

3. Click the Confirm button to delete the diagnosis.

4. Click the Done button to exit delete mode.

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