Add History Details

During a consult, record a patient's history on the History panel.

About this task

Procedure

To record a patient's history:
  1. In the patient's record, select the Consult buttonConsult panel.
  2. In the Consult panel, in the Consult Notes section, click Hx/Ex.
    The History and Examinations modules are linked. When you click Hx/Ex, History is displayed by default.
    History | Examinations toggle button
    Along the top of each module are tabs for accessing different input sets. This example shows the General tab.
    Example CVS History tab

    For more information, see History Categories.

  3. In the relevant category, record the required history information.
  4. If you want to specifically indicate No Abnormality Detected for a category, click NAD category: in our example, NAD CVS.
  5. If you want to clear a category of all information, click Reset category.
  6. Click Add to Notes.

Results

When a consult is exited, the history information from the current tab and all other tabs that have been updated, is added to the patient's timeline. For example:
Example patient history in the patient timeline