Document Gynecologic History
- Click the LMP date in the LMP field.
- If the LMP was entered on the Vital Signs template, then it appears automatically.
- Click the Estimated checkbox.
- Select a date in the Last pap field.
- If a Pap smear was entered in the Pap smear grid on the Abnormal Pap HPI or OBGYN Synopsis templates, the system fills in the date.
- Click the Patient reported checkbox if applicable.
- Click the Last mammogram field.
The Historical Test – Quick Entry template opens.
- Select the applicable option from the Mammogram grid.
The Test description and Test code fields display the details of the selected option.
- Select a date in the Date done field.
Entering a date value satisfies the Care Guidelines Mammogram entry.Note: The entered information displays in the Diagnostic Studies grid.
- If appropriate, enter the interpretation and results in the Interpretation and Results fields. These are optional fields.
- Click Save & Add New.
The date and test description displays in the Historical tests/exams entered this visit grid.
- Click OK.
- Select the Patient reported checkbox.
- Click Save & Close.
- Verify that today's date appears in the Last Clinical Breast Exam field.
Note: The date of last clinical breast exam is populated when it is documented in the Physical exam panel in the SOAP template.