By default, you will find the Medical Information section in the following notes and treatment report: Intake Note Other Sections, Progress Note Optional Sections, Inpatient Treatment Plan, and Outpatient Treatment Plan Other Sections. You can also set it up to appear in any note or report.
There are two sub-sections one for Health and one for Medical Review.
Health
Use drop down list to rate patient's General Health, or type in field.
To Add an Illness
| 1. | Click the blue underlined text Add Illness. |
| 2. | Enter illness in pop-up dialog box. Use drop down pick list to select, or type in field. Enter details for History, Treatment, and M.D. |
| 3. | Click OK. |
To Edit an Illness
Select illness from list, and click the blue underlined text 'Edit Selected Illness', or double-click on the illness.
To Delete an Illness
Select illness from list and press Delete key, or drag and drop into trashcan.
Allergy
Enter Allergy information in text field, if applicable.
Medical Review
Click Medical Review at top of screen. Enter data for:
| • | Vital signs |
| • | Current (non-psychotropic) Medications |
| • | Immunizations (for children) |
The Review of Systems, once a part of the Medical Info, is now a separate section. You can add the Review of Systems in the Documentation Setup.
See Also