Adding History Items

Add past and current, active conditions.

Procedure

To add a condition:
  1. From the Clinical Window, select the Past History tab.
  2. Then, either:
    • Select Edit > Add from the menu bar
    • Click Add on the toolbar
    • Press F3
  3. In the New History Item window, enter the year in which the condition first appeared.
  4. Enter the date on which the patient first alerted you to the condition in the format dd/mm/yyyy. 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.
  5. Select Pick from list (coded) and start typing the condition in the text field. Select the condition from the DOCLE list.
  6. Alternatively, select Free text (uncoded)and enter a custom condition in the text field.
    Important:
    If you enter a custom diagnosis it will not be coded and will not be included in searches. This is particularly important for Chronic Disease Management and for condition decision support options.
  7. Select other options as necessary:
    • Left, Right or both sides.
    • Active problem if this condition is still active.
    • Confidential 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.

    • Summary to include the condition in patient's summaries.
  8. In the Comment field, provide any other relevant information.
  9. Click OK to confirm the new condition.

Results

The condition is listed on the Past History tab.