Document the Interim History

You can document all patient medical encounters, which includes but is not limited to, hospitalizations, emergency room visits, office visits, and same day surgeries.

1. Open the Histories template.
2. In the Medical/Surgical/Interim panel, select Interim History.
   The Interim History window opens.

   

3. Select an encounter type. If an encounter type does not appear in the list, you can manually enter it.
4. 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.
5. 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.
6. In the Management field, enter the therapy or procedure performed on the patient.
7. 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.
8. Enter admission details, discharge details, and outcome or detail of the therapy or the procedure.
9. Enter discharge diagnoses (up to four), additional comments, and then select Save.
10. To document another interim history record, select Clear For Add.
11. Select Close.
    The interim history record appears in the grid in the Medical/Surgical/Interim panel.