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EHR Medical Information

For EHR, the Medical window is a central location for entering a patient's medical information, including problems, medications, allergies, and family health history.

To access the window, double click in the pink area in the Patient Info area of the Chart module.  In can also be accessed via the EHR Dashboard.

Problems:  A list of the patient's active or resolved Problems.  Active problems show in the Chart module, Patient Info medical area in bold red.

  • Click Add Problem to select a problem from the Master List.
  • Double click a problem to change start/stop dates, status, or notes.
  • Check Show Inactive Problems to list problems with an 'inactive' status. 

Medications:  A list of the patient's active Medications

  • Click Add Medication to select a medication from the Master List.
  • Double click a medication to change start/stop dates, provider, count, instructions, and refills. 
  • Check Show Discontinued Medications to list medications that have a Stop Date prior to today's date. 
  • Click Print Medications to print the list.
  • Current Meds Documented:  This information is used for the Clinical Quality Measure "Document Current Medications".  For every encounter with a patient 18 years and older, the provider should attest that current medications are documented to the best of his/her knowledge and ability.  Each time Yes is checked, the CQM numerator is affected. See Attest that Current Medications are Documented.

Allergies:  A list of the patient's active Allergies.  Active allergies show in the Chart module, Patient Info medical area in bold red.

  • Click Add Allergy to select an allergy from the Master List.
  • Double click an allergy to edit.
  • Check Show Inactive Allergies to list allergies that have been marked inactive.

Family Health History:  Document the patient's family health history. See Enter Family Health History.

The information below shows in the Chart module, Patient Info medical area as a summary.

  • Premedicate:  If checked, Premedicate will show in bold red in the medical summary, when you hover over an Appointment, and when you add PremedFlag to an Appointment View.
  • Med Urgent:  Show in bold red in the medical summary, when you hover over an Appointment, and when you add MedUrgentNote to an Appointment View.
  • Medical Summary:  Summarizing information about the patient's medical status.
  • Service Notes:  Useful information that is learned through discussions with patients, such as hobbies, employment, whether they need a blanket or pillow, nervous behavior, whether they are on a strict budget, whether they have to drive a long way to get to the office, etc.

Print Medical:  Print a list of the patient's problems, allergies, medical history, premedicate status (Y/N), medically urgent notes, and medical summary.

Medical History:  This section should always reflect the current medical status. The assistants should type in all items that the patient marks on a medical history form. Once the data is entered into the computer, the dentist can refer to it more easily than the handwritten patient version. There is no archiving or update mechanism, so all changes should also be entered as chart notes. 

 

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