Viewing Medical History

Its important that anyone interacting with a patient file is aware and can access Medical History data.

The Medical Record Status is a highly visible indication of how in-date a patient's medical record is. It indicates whether the record is in date, needs to be updated, or has not yet been created.

You can view a patients Medical History by going into the patient file and clicking on the Medical Tab.

The current status of the patient's medical record, (with the date it was last updated), displays at the top-left of the Medical tab screen, colour-coded for easy visual identification:

Open

Statuses

Open Records are up-to-date.

Records are older than the specified age, or the Update Medical History at next opportunity checkbox next to it is ticked (you can place a tick in this checkbox to force an update of the patient's medical record).

Medical details have never been entered (this status may also appear as a blank yellow bar).

You can optionally prompt an update of the medical history form for a patient:

Select (check) this check box to inform the system that the medical history form is out if date (even if it isn't), or the system has no limit set for updating medical histories.

The system will automatically uncheck this checkbox when the medical history is updated.

Viewing and using the Medical History List

The list of medical details and notes is in the main part of the Medical tab screen, arranged by date:

List contents

The list contains the patient medical history and notes, including

• Medical History Questionnaires

• Medical History Scanned Forms

• Notes

• Prescriptions

You can double-click most item types in this list to view a more detailed popup.

NOTE: There is no popup for prescriptions - you will see one line for each prescribed item though, and text as will fit on the remainder of the line. In most cases there is nothing further to show because the window is full width.

The Type column has a graphic and label to show what medical details were entered on that date:

Showing an Audit Trail of Medical History

1. Select Show Audit.

    

   The historical details of each voided item displays in italic type. For example:

    

2. To hide the Audit again, de-select Show Audit.

Viewing the Medical Status Icon

To instantly view MEDICAL STATUS from any tab in the patient desktop

The medical status icon is accessible from all of the tabs in the Patient file, providing a quick visual indication of the patient's medical condition and the status of their medical record.

To instantly view MEDICAL HISTORY from any tab in the Patient desktop

Hover your mouse cursor over the medical icon to display a Medical History (tooltip), showing a summary of the patient's current medical status, medical history, and the most recent notes entered:

When you move your cursor away, the tooltip disappears. You can also click the icon to open the summary on the screen (you will need to click a Close button to close it).

The Medical Status icon can be activated or changed from the bottom right of the Medical tab screen.

Icon states:

There is no medical history information recorded for this patient.

The medical history is up to date, and there are no alerts (for infectious diseases or medical conditions).

Medical history up to date, infectious alert.

Medical history up to date, medical condition alert.

Flashing between Yellow and Red indicates that both Infectious and Alert have been set.

Any of the three statuses can also have a note icon attached, which shows the record needs updating. This can be because the medical notes are more than the set number of months overdue, or because someone has ticked the Update Medical History at next opportunity checkbox at the top of the screen.

To temporarily display a summary of the Medical History you can use the tooltip.

From any tab in the interface, hover your mouse cursor over the medical icon in the button bar:

The tooltip will continue to display as long as the mouse cursor remains over the icon or the tooltip itself.

The tooltip display depends on what medical history has been configured (the top area), and what notes have been created for this patient (the area below the line).