It's important that anyone interacting with a patient file is aware and can access Medical History data.

The Medical Record Status is a highly visible indication of how in-date a patient's medical record is. It indicates whether the record is in date, needs to be updated, or has not yet been created.

You can view a patients Medical History by going into the patient file and clicking on the Medical Tab.

The current status of the patient's medical record, (with the date it was last updated), displays at the top-left of the Medical tab screen, colour-coded for easy visual identification:

• Statuses
• Viewing and using the Medical History List
• List contents
• Showing an Audit Trail of Medical History
• Viewing the Medical Status Icon
• Viewing CliniPad/Portal signed Forms

Statuses

You can optionally prompt an update of the medical history form for a patient:

Select (check) this check box to inform the system that the medical history form is out if date (even if it isn't), or the system has no limit set for updating medical histories.

The system will automatically uncheck this checkbox when the medical history is updated.

Viewing and using the Medical History List

The list of medical details and notes is in the main part of the Medical tab screen, arranged by date:

List contents

The list contains the patient medical history and notes, including

• Medical History Questionnaires
• Medical History Scanned Forms
• Notes
• Prescriptions

You can double-click most item types in this list to view a more detailed popup.

The Type column has a graphic and label to show what medical details were entered on that date:

The medical history was updated

General note

Note about a prescription (there is no popup for prescriptions as most information is already visible)

Referral letter to/from a specialist

Notes to/from a doctor

Notes related to an examination

Notes regarding patient's hospitalisation

Notes regarding infectious or medical conditions

Showing an Audit Trail of Medical History

1. Select Show Audit. The historical details of each voided item displays in italic type. For example:
   
2. To hide the Audit again, de-select Show Audit.

Viewing the Medical Status Icon

The medical status icon is accessible from all of the tabs in the Patient file, providing a quick visual indication of the patient's medical condition and the status of their medical record.

Hover your mouse cursor over the medical icon to display a Medical History (tooltip), showing a summary of the patient's current medical status, medical history, and the most recent notes entered:

When you move your cursor away, the tooltip disappears. You can also click the icon to open the summary on the screen (you will need to click a Close button to close it).

The Medical Status icon can be activated or changed from the bottom right of the Medical tab screen.

Icon states:

	There is no medical history information recorded for this patient
	The medical history is up to date, and there are no alerts (for infectious diseases or medical conditions)
	Medical history up to date, infectious alert
	Medical history up to date, medical condition alert
	Flashing between Yellow and Red indicates that both Infectious and Alert have been set
	Any of the three statuses can also have a note icon attached, which shows the record needs updating. This can be because the medical notes are more than the set number of months overdue, or because someone has ticked the Update Medical History at next opportunity checkbox at the top of the screen.

To temporarily display a summary of the Medical History you can use the tooltip.

From any tab in the interface, hover your mouse cursor over the medical icon in the button bar:

The tooltip will continue to display as long as the mouse cursor remains over the icon or the tooltip itself.

The tooltip display depends on what medical history has been configured (the top area), and what notes have been created for this patient (the area below the line).

EXACT V13.795 has introduced improved visibility of the medical history status to help identify when an out of date patient medical history is more obvious. 

Viewing CliniPad/Portal signed Forms

Double Clicking any Medical History will fully open it on screen. If a patient has completed this form via CliniPad or Patient Portal there will be a Form icon in the bottom left. Clicking this icon will open the PDF (CliniPad) or HTML (Portal). This can then be printed or emailed to the patient if required.

See: Reviewing Medical History