Adding Medical and Surgical Histories

You can enter the patient's medical and surgical histories on the Manage Past Medical/Surgical History template.

The following table describes the fields on the Manage Past Medical/Surgical History template. You can use the fields in the Disease/Disorder section for adding the medical history and those in the Management section for adding the surgical history of a patient.

Field	Description
Disease/disorder	Displays the option selected on the Past Medical History template. Note: If this template is opened through the link in the options, you can click the list icon to select the body part and the search icon to search for the disease or disorder of the selected body part. You can also type the keyword of the disease or disorder and click the search icon.
SNOMED code	Displays the concept ID of the selected disease or disorder.
Onset date	Displays the onset date selected on the Past Medical History template. If this field is blank, you can manually enter the date when the disease or disorder first appeared for the patient or click the calendar icon to select the date. Note: An exact date is not required. You can enter only the year. When you add a value in the Onset age field without entering the onset date, the Onset Date field is automatically filled with the year of onset for the patient.
Side	You can select the side of the body from the list.
Onset age	On the Onset age window, you can enter the age of the disease. Note: After you enter the age of onset, the Onset Date field is automatically filled with the year of onset for the patient.
Management	Displays the option selected on the Past Medical History template. Note: If this template is opened through the link in the options, click the list and search icons to select the procedure. You can also type the keyword of the procedure and click the search icon.
SNOMED code	Displays the concept ID of the selected procedure.
Date	Displays the date selected on the Past Medical History template. If this field is blank, you can manually enter the date of the procedure or click the calendar icon to select the date. Note: An exact date is not required. You can enter only the year. When you add a value in the Age field without entering the date, the Date field is automatically filled with the year of procedure for the patient.
Side	You can select the side of the body from the list.
Age	On the Age window, you can enter the age of the procedure. Note: After you select the age, the Date field is automatically filled with the year of procedure for the patient.
Facility	You can select the facility where the procedure was performed.
Provider	You can select the provider. When you select the provider, the last name and first name fields are automatically filled.
Procedure	You can select the appropriate option from the list. When you select the procedure, the CPT field is automatically filled.
Body site	On the SNOMED Search window, you can select the area of the patient's body where the procedure is performed.
Outcome	You can select the outcome from the list.
Comments	To enter any additional details.

Adding Medical and Surgical Histories

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