Add Medical and Surgical History

You can add the medical and surgical history of a patient on the Histories template or the History Summary panel.

1. Open NextGen® Enterprise EHR.
2. To open the Past Medical History template, do one of the following:
   • On the Histories template, select Medical/Surgical/Interim, and select Add.
   • In the History Summary panel on Intake, select Past Medical/Surgical, and select Add.
3. To document a medical condition or surgical procedure on the Past Medical History template, select the condition in the Medical or Surgical panel.
   Based on the selection, the Onset Date field appears in the Medical panel or the Date field appears in the Surgical panel along with the Details icon beside the selected condition.

   Note: To add problems that are not available on the Past Medical History template, you can use the Other field, and search for and select the problem.
4. To add additional details to the selected medical condition or surgical procedure, do one of the following:
   • To enter the date on which the condition first appeared or the date the surgery is performed, do the following:
     • Select Onset Date or Date.
     • Enter the date on the Data Selection window.
     • Select Add To Grid.
   • To add onset date and additional description, select the Details icon beside the selected condition or procedure.

     The Manage Past Medical/Surgical History template opens.

     • Document the details on the template.
     • Select Save to Grid & Close.

     The details of the selected condition or procedure appear in the grid in the Past Medical History panel.

5. Select OK.
   The history records appear in the Past Medical History or Past Surgical History grid in the History Summary panel.