Past Medical History Encounter Section

The Past Medical History encounter section displays in the visit encounter Subjective. If the patient/employee has a known past medical history, the conditions will display by default in a bulleted list on the left side of the Past Medical History encounter section. Additional options are located on the far right side of the encounter section header.

Users have the option to view the past medical history in a grid format rather than the default bullet list.

Users have the option to pull the past medical history from prior encounters used by themself and other providers and copy them to today’s past medical history.

Users can click the ribbon icon to display the Quick List. Quick Lists allow the adding of new conditions to the past medical history. A My Setting preference is also available to set all encounter sections to display Quick Lists for all encounter sections by default.

Users have the option to change from the default library to custom libraries on a per encounter section basis. Users may also set a default library that applies to all encounter sections in the encounter header.

Users may click on the pencil icon to open the Add Condition entry box. Users may also simply click on the gray Past Medical History bar to open the Add Condition entry box.

The X icon will remove the Past Medical History section from the encounter. The section can be re-added by clicking the gears icon in the encounter header.

The microphone/dictation icon can be used to add dictation. For clients using the Dictation module, a transcriber can transcribe the audio into the dictation. For users utilizing Whisper AI, AI will transcribe the dictation directly in the encounter upon uploading the voice file.

Managing Conditions

Hovering over the condition list will display options to help manage each existing PMH condition.

Opens the Edit Condition screen. Users can add/remove the condition from the Problem List and/or Past Medical History, designate the Clinical Status, Verification Status, Managed by, as well as enter comments, view revisions, view links and related conditions.

Removes the condition from today’s PMH. The condition will still display in the Quick List and can be added back to today’s PMH if removed in error.

Opens the Remove Condition screen. Users can remove the condition from today’s PMH and the patient/employee’s PMH, indicate if it should be deleted as an entry error, add comments, view revisions, view links and related conditions.

Opens the Notes screen. Users can add notes to the PMH condition, indicated E&M category or mark the note as private. Previously entered notes on the condition will be dated and displayed in gray under the Add a new note entry box.

Opens the Add Task screen. Add Task allows the user to send a task note to a department or individual user a task note regarding this condition.

Opens the Add Encounter Order screen. This allows the user to add encounter orders using the selected conditions as the reason for the order. Any orders entered will display in the Plan Visit Orders encounter section.

Click to drag and drop and reorder the conditions as they display on the PMH list.

As of RC202203, users will no longer be able to open/close the Past Medical History section and use the legacy list edit to add or edit the PMH. Beginning RC202203, users must use the Quick List to manage the PMH. Use the Quick List on the right side of the encounter section to add conditions to the PMH. If a condition has previously been added to the PMH, it will display on the left side of the Past Medical History section.

No Past Medical History

For clients on 202403 and newer, the Past Medical History Encounter Quick List includes an option for “No Past Medical History”. The “No Past Medical History” option will ONLY display in the Quick List if no other PMH conditions are already listed on the chart.

If “No Past Medical History” is the only item on the patient’s PMH condition list, and the user attempts to add a new condition to the PMH, the system will prompt the user asking if they would like to remove “No Past Medical History” from the chart.

This functionality will also carry over to the Conditions chart tab for clients who use the Conditions chart tab to manage the Past Medical History.

Using the Past Medical History Quick List

Past Medical History Search

Begin to type the condition in the Search field. This is NOT an autocomplete. However, if you begin to type the condition in the search and click the “+” icon next to the Search field, the Add Condition screen will appear and locate possible conditions that match what you typed in the Search field.

Or simply click the “+” icon and begin typing the condition in the Add Condition “Name” field. The Name field in the Add Condition screen is an autocomplete field.

Click the “double arrow up or down” icons to open/close all Quick List items in the Past Medical History all at once. Or the “single arrow up or down” to open or close each individual Quick List section of the Past Medical History.

Problem List Quick List

See My Settings section of this document for related user preferences.

The Problem List section of the Quick List contains any new or previously added problem list conditions. Once the condition has been added to the PMH, the Problem List Quick List, hover over the condition to see additional options.

The additional options are Edit, Remove, Move to Past PMH, Add to PMH.

Edit

Selecting the edit opinion on a problem list condition will call the* Edit Condition* screen. This allows the user to edit the condition description and/or attributes of the condition.

If a condition is marked as “Yes” to Problem List and “Yes” to Past Medical History, the condition will display in the Problem List Quick List only.

Unconfirmed conditions will not display in the Problem List Quick List.

Conditions with a Clinical Status of Inactive, Remission or Resolved, and a Verification Status of Confirmed will continue to display on the Problem List Quick List as “(Inactive)”. The visit note documentation will also display the Clinical Status in light gray colored text to the right of the condition name.

Remove

Selecting the Remove icon will call the Remove Condition screen. This screen allows users to remove/resolve the condition from the Problem List and Past Medical History Quick Lists. This may be because the condition was concluded or it was an error and shouldn’t have been in the medical history.

Users can also view historical revisions for this condition, notes, tasks and links.

Move to PMH

If the condition was previously set to Problem List, “Yes” and Past Medical History, “Yes”, then when the ‘Move to PMH’ button is selected, the condition will move from Problem List Quick List to the Past Medical History Quick List.

Note: The “Past Medical History” Quick List will display “Patient Past Medical History” for Webchart systems and “Employee Past Medical History” will display for Enterprise Health systems.

If the condition was previously set to Problem List, “Yes” and Past Medical History, “No”, then when the ‘Move to PMH button’ is selected, the condition will move to the Other Problems Quick List.

Add to PMH

If the condition was previously set to Problem List, “Yes” and Past Medical History, “No”, then when the ‘Add to PMH button’ is selected, the Edit Condition screen will display.

If the condition should be marked as “Past Medical History” on future encounters, manually click the “Yes” radio button and then click “Save”. This adds the condition to the encounter (left side of the encounter section).

Employee/Patient Past Medical History Quick List

The “Past Medical History” Quick List will display “Patient Past Medical History” for Webchart systems and “Employee Past Medical History” will display for Enterprise Health systems.

Existing conditions in the Past Medical History encounter section and the Conditions chart tab will pre-populate the Past Medical History Quick List.

When adding/editing a condition via the Quick List, if a condition is marked as “Yes” to the Problem List, and “Yes” to the Past Medical History, the condition will display in the Problem List Quick List only.

When adding/editing a condition via the Quick List, if a condition is marked as “No” to the Problem List, and “Yes” to the Past Medical History, the condition will display in the Past Medical History Quick List only.

Selecting “Yes” to Past Medical History will also display the condition to the chart/encounter Past Medical History section, and to the Past Medical History Quick List for today and all future encounters created.

Once the condition has been added to the Past Medical History Quick List, hover over the condition to see additional options.

The options are Edit, Remove, Move to Problem List and Add to PMH:

Edit

Selecting Edit from the Past Medical History List will call the Edit Condition screen. This allows the user to edit the condition description and/or attributes of the condition.

If a condition is marked as “Yes” to Problem List and “Yes” to Past Medical History, the condition will display in the Problem List Quick List only.

Conditions with a Clinic Status of Inactive, Remission or Resolved, will continue to display in the Past Medical History Quick List and display the text “(Inactive)” after the condition name.

Unconfirmed and Refuted conditions will not display in the Past Medical History Quick List. The verification status does however display in the encounter documentation, and will be memorialized in the archived encounter and document.

Remove

This will call the Remove Condition screen. This allows users to remove/resolve the condition from the Problem List and Past Medical History Quick Lists.

Move to Problem List

When selected, the condition on the Past Medical History Quick List will move to the Problem List Quick List and add the condition to the encounter PMH (left side of the encounter section).

Add to PMH

Selecting Add to PMH will add the condition to the encounter PMH (left side of the encounter section).

Other Problems Quick List

Conditions in the Other Problems list are conditions that were added and not indicated to be on the Problem List or the Past Medical History Quick Lists. Examples might include quality care or administrative codes.

If a condition is marked as “No” to Problem List and “No” to Past Medical History, the condition will display in the Other Problems list only.

The options are Edit, Remove and Add to PMH.

Edit

Selecting Edit from the Past Medical History List will call the Edit Condition screen. This allows the user to edit the condition description and/or attributes of the condition.

Remove

This will call the Remove Condition screen. This allows users to remove/resolve the condition from the Problem List and Past Medical History Quick Lists.

Add to PMH

When selected, the condition on the Make New PMH Item Quick List will move to the Problem List Quick List and add the condition to the encounter PMH (left side of the encounter section).

Make New PMH Item Quick List

Conditions in the Make New PMH Item Quick List are conditions predefined in the Default Library. This list can be managed in the “Library, Default” chart. Providers may also create their own customized Libraries and manage their own list of Quick List defaults. See additional information online regarding custom libraries and how to set them up and apply them to encounters.

The options are Add to PMH and Add to Problem List:

Add to Past Medical History

Selecting Add to PMH will add the condition to the encounter PMH (left side of the encounter section) . This condition will also now display on the Employee/Patient Past Medical History Quick List.

Add to Problem List

Selecting Add to Problem List will add the condition to the encounter PMH (left side of the encounter section) . This condition will also now display on the Problem List Quick List.

My Settings

Problem List Default on New: Default is “No”.

When set to No, the Problem list and Past Medical History radio button will default to “No” upon adding an assessment.

When set to Yes, the Problem list and Past Medical History radio button will default to “Yes” upon adding an assessment.

When set to Yes, but the Problem list and/or the Past Medical History radio button is set to “No” and you click one to be “Yes”, then BOTH radio button options will change to yes.

Show Dynamic List Options: Default is set to “On hover”

If this setting is changed to “Always”, then all options in the encounter and/or other areas where icons are dynamic will display. This is typically discouraged and clients should be encouraged to use the hover.