Working with the Medical History

Article author
Dan Jordan
  • Updated

What's the context?


The patient's Medical History section provides a thorough summary of all past and present clinical data on a patient's record; including data recorded during an appointment.

The Medical History is grouped into separate sections based on where data is entered in Clinical forms and how the data is added using the Medical log.

What is the purpose of the article?


This article outlines what you can do in the Medical History.

How do you access the Medical History for a patient?


If you are not sure how to get to the Medical History for a patient, this is explained in the separate article How to view the Medical History.

What can you do in the Medical History?


When the Medical History is displayed, there is a range of features and data you have available. What you can see and do are summarised in the table below and then explained in the consequent sub-sections. 

Important note: Any information recorded in the patient's Medical History section may be included in calls to Multilex if it has been associated with a SNOMED code. Attendees should subsequently review all the patient's medical history at the start of a consultation, and mark any resolved issues as historical, to ensure that only information which is active and relevant is passed in calls to Multilex.

 

Summary table showing what you can do in the Medical history
1. Filter the Medical Record 2. View and update Numerical data 3. View Numerical data field history chart and table
4. Add Medical log records 5. Navigate and filter the Medical History Timeline 6. View Allergies
7. View Complaint information 8. View Drug History information 9. View Diagnoses
10. View & Manage Documents 11. View Examination information 12. View Family history
13. View Past medical history 14. View & Manage Prescription records 15. View Social History
16. View Treatment information 17. View Pathology Results 18. View Vaccination information
19. View Deleted information 20. View History information 21. View Field History

Filter the Medical Record


The Medical Record section at the top left of the page provides the opportunity to look at different views of the data according to criteria of:

  • Status
  • Years
  • Appointments
  • Categories

For example, by making a selection of one of the Categories, the Medical History Timeline on the right-hand side is filtered to show information relevant to that category.

By_selecting_a_category_in_Medical_Record_panel_-_time_line_is_filtered

View and update Numerical Data


The Numerical Data section at the bottom left of the page provides a view of numerical data (e.g. Weight (kg), Height(cm), BMI and Blood pressure).

Numerical_data_in_the_Medical_History

It can also be viewed when navigating the Medical History Timeline.

This data can be created and updated through:

  • Data entry when using a Clinical Form during a consultation
  • Manual entry in the Numerical Data section

View Numerical data field history chart and table


As well as viewing the current value for numerical data, you can see historical values in tabular and graphical chart format.

By clicking on the date and time to the right of a Numerical Data value, it opens a new tab showing a chart and table of values for that numerical field.

Select_numerical_data_value_to_view_chart_of_value_histories

Add Medical log records


The Medical log in the top right allows you to record medical entries that are then added to the Timeline in the Medical History. 

To record a Medical log entry:

1. Key in required text in the field in the Medical log section

2. Click on the Log button

3. In the dialog that appears, choose from the type list to classify the entry

4. Click on Submit

Adding_an_entry_via_the_Medical_log

The record is then added to the Timeline of Medical History records.

The Medical log can be used to make on-the-fly entries where setting up an appointment is not necessary.

Please note: Data entered into the Medical Log field in the Medical History view is not subject to SNOMED CT matching. Attendees should subsequently avoid using this field to record active conditions or allergies to avoid the information being unavailable for prescribing decision support.

 


The Timeline section in the Medical History shows a series of cards with different types of data and information.

In this section, there is always a Medical record: Summary towards the top with further records showing different categories of data, and documents, in discrete cards. These cards are shown in chronological order with the most recent items at the top.

In the Timeline section you can:

  • Scroll through the records
  • Jump to information for a specific appointment
  • Filter by Status, Years and Categories

5_-_Medical_History_timeline.gif

View Allergies


After allergy information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Allergies recorded for the patient as part of the Medical record: summary
  • View specific Allergies recorded as part of an Appointment Episode in the Medical History Timeline

View_list_of_allergies_on_Medical_record_summary

Note: When recording a new allergy or condition in a patient's medical history, the system will not trigger decision support checks against currently prescribed medications. It is the responsbility of the prescriber to verify that any current medications are in no way contraindicated as a result of new allergies or conditions that may have materialised.

View Complaint information


After complaint information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View specific Complaint information recorded as part of an Appointment Episode in the Medical History Timeline

View_Complaint_information_as_part_of_an_appointment_episode

View Drug History information


After Drug History information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Drug History records for the patient as part of the Medical record: summary
  • View specific Drug History information recorded as part of an Appointment Episode in the Medical History Timeline

Please note: Medications recorded in the Drug History section of a consultation form will not be passed to the decision support engine regardless if associated with SNOMED CT codes. This means, Clinicians should subsequently use the Drug History field for recording stopped medications which the patient is no longer taking.

View_Drug_history_information_medical_record_summary

View Diagnoses


After Diagnosis information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Diagnoses records for the patient as part of the Medical record: summary
  • View specific Diagnosis information recorded as part of an Appointment Episode in the Medical History Timeline

View_Diagnoses_on_the_Medical_Record_Summary

View & Manage Documents


After documents have been added to the patient record you can:

  • View documents in the Medical History Timeline
    • Where it is a pdf you can see a formatted preview of the document

You can also:

  • Open a document
  • Delete a document
  • Share a document with the patient or employer
    • Where they are using the Patient Portal or Referral Portal respectively

View_a_document_in_the_Medical_History

The ability to view pdf previews in the Medical History is dependent on a configuration setting. This configuration explained in the article Configuring and Using PDF previews.

View Examination information


After examination information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View specific Examination information recorded as part of an Appointment Episode in the Medical History Timeline

View_Examination_as_part_of_an_appointment_episode

View Family history


After Family history information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Family history records for the patient as part of the Medical record: summary
  • View specific Family history information recorded as part of an Appointment Episode in the Medical History Timeline

View_Family_History_information_on_the_Medical_Record_Summary

View Past medical history


After Past medical history information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Past medical history records for the patient as part of the Medical record: summary
  • View specific Past medical history information recorded as part of an Appointment Episode in the Medical History Timeline

View_Past_Medical_History_information_on_the_Medical_Record_Summary

View & Manage Prescription records


After Acute and Repeat prescriptions have been created you can:

  • View a consolidated list of Prescription records for the patient as part of the Medical record: summary
  • View specific Prescriptions information recorded as part of an Appointment Episode in the Medical History Timeline

But you can also:

  • Print a Prescription
  • Open a Prescription
  • Edit a Prescription (after it has been opened)
  • Delete a Prescription

View_a_Prescription_created_as_part_of_an_appointment_episode

If you delete a prescription, the data is retained and can be viewed when the Deleted status filter is applied.

Please note: The list of prescribed medications should be reviewed at each consultation and any stopped items should be deleted from the list. To fail to do so could result in decision support warnings being generated inappropriately at the point of prescribing.

Please note: Only medications recorded in the Prescriptions section of Meddbase, will be passed to decision support. Information recorded in the Drug History section of a consultation form are not passed to the decision support engine at the point of prescribing. Users must therefore ensure they independently verify that a medication is not contraindicated by other medications which the patient may be taking but are not recorded as prescriptions in the system.

 

View Social history


After Social history information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Social history records for the patient as part of the Medical record: summary
  • View discrete Social history information recorded as part of an Appointment Episode in the Medical History Timeline

View_Social_History_in_the_Medical_Record_Summary

View Treatment information


After Treatment information has been recorded in a Clinical form as part of an episode within an appointment, you can:

  • View specific Treatment information recorded as part of an Appointment Episode in the Medical History Timeline

View_Treatment_information_as_part_of_an_appointment_episode

View Pathology results


After Pathology results have been returned you can:

  • View pathology results in the Medical Record

As an example, where integration is configured through a provider such as TDL, the results information is packaged as an episode in the Medical History.

View Vaccination information


After Vaccinations have been added as services to an appointment and recorded in a Clinical form as part of an episode within an appointment, you can:

  • View a consolidated list of Vaccination records for the patient as part of the Medical record: summary
  • View discrete Vaccination records in the recorded as part of an Appointment Episode

View_Vaccination_information_in_the_Medical_History_timeline

View Deleted information


By selecting the Deleted status value in the top left of the Medical History, you can view information that has been deleted and is not otherwise visible in the default Active view.

View_deleted_information_in_the_medical_history

View History information


By selecting the History status value in the top left of the Medical History, you can view a history of changes for information in the Medical History.

View Field History


By clicking on certain values in the Medical History Timeline, you can view current and historical values for that field.

View_field_history_for_field_in_Medical_history_timeline

 

Review date


This article was last updated on 6 March 2024 in the context of Meddbase version 1.246.0.35497.