Reviewing Medical History

From v11.10 EXACT includes a means of recording that Medical History records have been Reviewed.
Providers can record that they have Reviewed a patient's medical record, whether or not they changed that record.
Nurses without edit permissions can record that they have Reviewed read-only medical records.

Example: a patient's medical record was created 12 months ago.
At today's appointment the Nurse orally reviews the medical record with the patient.
The nurse selects a Mark as Reviewed button to record that the record still applies and is unchanged.

Mark as Reviewed:

Each time a Provider or a nurse opens an existing medical history form on screen, they will see an option to mark the medical history as Reviewed:

Nurse or Provider, from a read-only Medical History Form

Open

Provider, from an updated or a new Medical History Form

Open

Audit record of the Review:

Practitioners can see the audit record of any marked Review when they check (tick) the Show Audit checkbox in the Medical tab:

Circumstances where Mark as Reviewed applies:

• From the medical history tooltip.

• From a read-only view of a patient's Medical History Form.

• From creation of a new patient Medical History Form.

• From update of a patient's Medical History Form.

• From Clinipad Medical History Forms.

To record the Medical Record as Reviewed from the tooltip

1. Hover your mouse cursor over the medical alert icon

2. Check the patient's medical details against those displayed in the tooltip.

3. Click the Mark as Reviewed button:

   If your Medical History List has Show Audit checked (ticked) you will see a record of your review in the List.

To record the Medical History Form as Reviewed, without updating

1. Check the patient's medical details.

2. Open the Medical History Form:

    

   The Medical History Form will open in read-only mode.

3. Click the Mark as Reviewed button:

   
   
   

   
   
   

   
   
   

    

Clinipad:

To create, save and mark the Medical History Form as Reviewed

This is optional for Providers.

1. Open the form, review the medical details with the patient and check all appropriate checkboxes.

   You'll see an additional checkbox at the bottom of the form - Reviewed by [PROVIDER]:

    

2. To save without a Review record, simply click the Save button.

3. To both Save and record the Form as Reviewed,

   1. Check the checkbox.

      You will see the Save button change to a Save as reviewed button.

   2. Click the Save as reviewed button
      
      

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