Adding History Items

Before you begin

Procedure

  1. From the Clinical Window, select the Past History tab.
  2. Then, either:
    • Select Edit > Add from the menu bar, or
    • Click on the toolbar, or
    • Press F3 > .
  3. The New History Item window appears.
  4. Enter the year in which the condition appeared.
  5. Enter the date on which the patient first alerted you to the condition. The current date is displayed by default.

    CDA documents that display Past History items require that you have recorded the History items using a valid date format;

    The Date field in a CDA eHealth document displays;

    • As blank if the date and year are not recorded for the Past History item.
    • The year only, if the year is present but no date has been recorded, or if the year is present but the date field contains text which is not in a recognised date format, or is not a month (or abbreviation of) in the Past History item.
    • A date, if no year is present but the date is present in the Past History item.
    • Month and year, if month and year are recorded but no date is present in the Past History item.
  6. Enter/select the condition from the Pick from list (coded) DOCLE list, or enter customised text in the Free Text (un-coded) text box. Note that if you enter a diagnosis into the Past History tab that was not selected from the Pick from List it will not be internally coded, and as such will not be found when doing searches. This is particularly important for Chronic Disease Management or when using some supplied decision support options.
  7. Select check boxes as necessary.
    • Left, Right or both sides.
    • If this is still an 'Active problem' .
    • Select the 'Confidential' check box to prevent this item from being included in summaries. Only practitioners will see this entry - Nurse Practitioners and Practice Managers (for example) will not.. If you export the patient's record, the confidential information will be included in the exported data.
    • Select the 'Summary' check box if you want this history item to be included in patient's Summaries (printouts).
    • Add any 'Comments' required.
  8. Click OK to confirm the new item.

Results