Document Patient History for Post-Operative Visits

You can document a patient's history such as details of the last injection, pain, medications, and allergies for a post-operative visit.

1. On the Non Billable Visit template, expand the History panel.
2. Enter the details of the last injection in the following order:
   1. Click the Last Inj field, select the last injection date, and then click OK.
   2. Enter the duration of the relief in hours, days, weeks, and months.
3. Enter the details of pain as follows:
   1. Indicate the severity of the pain.
   2. Click the Pain Scale field, and select the pain scale from one to ten from the list.
   3. Click the Status % field, select the percentage of the pain status, and then click OK.
   4. Select one of the following to indicate the pain status.
      • B. Better
      • S. Same
      • W. Worse
4. In the Ambulatory Aids/Braces, Assoc Symp, and Function/Activity Level sections, do the following:
   1. Click the blank field, select the appropriate condition from the window, and then click OK.
   2. Indicate the applicability of the selected condition.
   Note: You can enter additional values in the subsequent fields of each section. If the fields in each section are not sufficient, you can enter additional values in the Overflow Type section.
5. Enter any additional history in the Additional History field.
6. Add the sports details and hobbies of the patient, if needed.
7. To add details of the patient's employer, click Add below the Employer field.
8. Add the details of the medications and allergies, if needed.