Medical History is separated into four different categories in this program: Past Medical, Past Surgical History, Social History, and Family History.These four categories are found in the form of buttons under the main menu in the EHR selection options.  Medical History sections are custom templates that can be modified to add custom sections with the following field types: texts, check box, pull downs, Boolean (yes/no), date, and word processors with selectable default text. Fields can also be set to appear based on patient gender These fields can be displayed in a table. Section names, field names, and value text can be set to appear in the note.  Default text can be created to appear in the note instead of the field values. 

Features of the Medical History screens:

Pull from Prior Exam:  This button allows the value from the prior exam for this section of the template to be seen during future exams.  The values can be modified and saved.

Insert Sentence: The Insert Sentence dropdown allows users to quickly insert predefined text or commonly used documentation statements. Choosing an item from the list automatically adds the related content to the text area, helping improve documentation speed and consistency.

Save: Providers can switch between sections and save all the data.  Saving the field values places a yellow check mark on the main menu to indicate that some information has been entered for this template.

Lock: This button prevents the data from being modified and changes the color of the check mark on the main menu to red, which signifies the template has been completed.  The template can be unlocked by clicking the Unlock button.

Clear: The Clear button is used to remove entered data from the current screen or template section. When clicked, it displays the following options:

• Clear Selected Section Data – Removes data only from the currently selected section or tab.
• Clear All Template Data – Removes all entered data from the entire template.

Print: The Print button opens a print preview screen displaying the patient’s visit summary and entered information in a printable format. From this screen, users can review the document, select an export format, print the report, or save/export the document if needed.