You can document all patient medical encounters, which includes but is not limited to, hospitalizations, emergency room visits, office visits, and same day surgeries.
- Open the Histories template.
- In the Medical/Surgical/Interim panel, select Interim History.
The
Interim History window opens.
- Select an encounter type. If an encounter type does not appear in the list, you can manually enter it.
- Select the Problem field.
If problems are added during previous encounters, the Patient Problems template opens. If there are no problems from previous encounters, then a search window opens.
- Do one of the following:
- From the patient problems list, select an existing problem.
- From the search window, search for and select a new problem and then select the Add to Problem List button.
Note: If you manually enter the problem, the Add to Problem List button is turned off.
- In the Management field, enter the therapy or procedure performed on the patient.
- Select the current date and then the provider who performed the therapy or procedure. If a provider does not appear in the list, you can manually enter their name.
- Enter admission details, discharge details, and outcome or detail of the therapy or the procedure.
- Enter discharge diagnoses (up to four), additional comments, and then select Save.
- To document another interim history record, select Clear For Add.
- Select Close.
The interim history record appears in the grid in the Medical/Surgical/Interim panel.
