Document the Interim History
- From the Histories template, expand the Medical/Surgical/Interim panel and then click 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.
- Click 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 click the Add to Problem List button.
Note: If you manually enter the problem, the Add to Problem List button is not enabled. - 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 click Save.
- To document another interim history record, click Clear For Add and click Close.
The interim history record appears in the grid in the Medical/Surgical/Interim panel.