Topics Past Medical History Search:  
Introduction: When a patient comes to a clinic, especially for the first time, the doctor/nurse will add entries to note down their medical history. For all subsequent encounters, the ailments diagnosed in the Assessment of each visit are added to the list of problems.

The PMH screen is divided into two sections: the Past Medical History and the Transition of Care sections. Reconciliation is done for the medical history, and there are two ways of adding problems or ailments to the patient's medical history, i.e., either via the Transition of Care section or through CCD-CCR. These entries are shown in gray and cannot be changed. Click the Plus button to open a popup window with a list of ailments. Select the required ailments to be added as part of the medical history.

Past Medical History (PMH) section

Existing/All Drop-Down List: Displays either the existing problems/ailments present in the patient's medical history list of problems whose Status is Not Recovered or displays the list of all problems, including the ones with the status as 'Recovered'. You can sort the list by ailment and know at a glance how often an ailment has been bothering the patient.
When the Status is marked as Recovered, the ailment is not shown in the Existing list of ailments, but will be visible in the All list.

No Known Medical History: This option, when selected, marks that the patient has no known medical history available.

Transition of Care for Past Medical History (PMH) section

The following field description is equally applicable to the PMH section.

Del: This option, when selected on a particular row, deletes that particular row of details on Save.

Add Ailments : Displays the problem list entered by the user explicitly (typically during the first visit) and the ICD Name + Code of ailments diagnosed in subsequent visits; click the button to add the ailments by selecting them from the list on the Add Problems popup. Upon selection, the selected items will appear in the table of the Transition of Care section. The user is allowed to edit the selected ailment. If a user tries to add duplicate ailments from the Add Problems popup and clicks the Save button, then a Duplicate Ailments popup is displayed, which shows the details of the duplicate ailments and prompts the user to select one of the two duplicate ailments to be added to the patient's PMH.

Code Button : Instead of defining the ailment in general terms, the doctor may refer to a very specific ailment defined by an ICD/SNOMED code. Click this button to select the required ICD/SNOMED from the Problem Codes popup list. Upon selection, the selected ICD/SNOMED will appear in the table. The user is allowed to edit the selected ICD/SNOMED.

 No Known Transition of Care Problems: This option, when selected, marks the encounter as having no reconciliation completed.

 Comments: Enter comments, if any, for the selected ailment or ICD.

 Since When Date: Either a manual entry of the date is made, or a particular date is selected from the 'Since When' calendar. The field accepts any text and is a non-mandatory field. This does not need to be an exact date; 'Jan 2000' is acceptable. If the row is autogenerated (e.g., if data is imported), this field shows the encounter date.

 Status: The possible status values are:
  1. Existing
  2. Existing Temporary
  3. Existing Better
  4. Existing Worse
  5. Existing No Change
  6. Existing Recurring
  7. Acute
  8. Chronic
  9. Recovered
  10. Inactive
The doctor can change the status of any problem by selecting it from the list box.

 Source: The drop-down list displays the various sources from which the problem has been added. It is a mandatory field.

•  The following table lists these sources and their descriptions:

Source Description
CCD The problem has been imported into the system through a CCD file.
OldPMH The problems added through the [+] button from the 'Transition of Care' section and selected with the value as OLDPMH. This is used when the client is new to PrognoCIS and old data is transferred.
MedHistory The problem has been added from the 'Medication History' popup.
Assessment

In the Assessment, when an ICD code is added with the MH (add to medical history) option selected.

Patient The problems or ailments manually added through the [+] button from the 'Transition of Care' section and selected with the value as Patient.
Ref Doc The problems manually added through the [+] button from the 'Transition of Care' section and selected with the value as Ref Doc (Referred by doctor).

Severity: Select the severity of the ailment. The following values are available in the drop-down list:
  • Mild
  • Mild to moderate
  • Moderate
  • Moderate to severe
  • Severe
  • Fatal
Problem Control: Select the current status of the problem to indicate whether it is controlled or not. The selected value is sent in the NAMCS (National Ambulatory Medical Care Survey) healthcare survey type of CCD. The following standard options are available in the drop-down list:
  • Moderately controlled
  • Well controlled
  • Existing worse
  • Slightly controlled
  • Uncontrolled
Reconcile: The drop-down list by default displays the value 'Add' for problems added via Ailments [+]/ICD [+], as well as for problems imported via CCD.

Note:

If the CCD file has been imported in an encounter of the patient, then the details of these imported problems are displayed on the Transition of Care section from the next encounter onward.
The Del checkbox is disabled for problems imported through CCD.
The Reconciliation drop-down list by default displays the value 'Add' for problems added via Ailments [+]/ICD [+], whereas it displays the value 'Select' for problems imported via CCD.
To add problems or ailments to the patient's current problem list from the Transition of Care section, the user has to select the Reconciliation action as 'Add' on the problem. To remove problems from the Transition of Care section, the user has to select the Reconciliation action as 'Remove' – this entry is not added to the patient's problem list.
Once an ailment or problem has been reconciled, that entry is removed from the Transition of Care section. Upon importing a CCD file for a problem, the SNOMED and ICD codes (optional) are available. In PrognoCIS, the ICD code is displayed under the Code column; thus, if the ICD code was not available in the CCD file, the column displays a blank value, and the SNOMED code is available as a tooltip on the problem name.

Last Modified: This field displays information such as the latest modified date, time, and time zone of the clinic location.

 Edu Icon : The Patient Education icon, when clicked, invokes the Patient Education popup; the material displayed is sourced from MedlinePlus. Based on the patient's preferred language, the MedlinePlus Education material is displayed in that respective language. The user has the option to either print the material and give the patient printed copies, or send the same as an email to patients.

Notes: Add notes with phrases to the patient's Past Medical History. You can do this by using an acronym. Favorite acronyms are shown in the autocomplete search. Select any acronym or type the acronym and press the Tab key to populate the Past Medical History Notes. You may also click the Insert Phrases search button to add a phrase from the Fast Phrases search popup. Click the Zoom Notes icon to open and view the notes in the Past Medical History Notes popup.
Note:

In a patient encounter or Assessment, when an ailment is diagnosed, the doctor will flag it to be added to the Medical History. If it was a minor or temporary ailment, then the doctor will not flag it. If it is added to the Medical History, there are three possibilities:

  1. The diagnosed ailment (ICD code/name) does not exist in this list. A new entry is auto- generated, 'Since When' is set to the encounter date, and the 'Status' is set to Existing.
  2. If the problem exists and the status is 'Not Recovered', then a new entry is not generated.
  3. If the problem exists and the status is 'Recovered', then a new entry is autogenerated, with 'Since When' set to the encounter date and the status set to 'Existing Recurring'.

Problems are marked as duplicates based on each of the following criteria:

  1. ICD
  2. SNOMED
  3. Ailments
  4. Edited Ailments (i.e., problems)

The user has to choose a problem from the Duplicate popup; the chosen problem is added or updated in the PMH list, whereas the remaining problems are marked as deleted.

Save button: Clicking this button saves the details.

Close button: Clicking this button closes the PMH screen.

History button: Clicking this button displays the 'PMH History' popup, which shows the trace or log history of problems added and/or modified by the user.

Print button: Clicking this button prints the clinic details as a header, followed by the patient details and the patient's past medical history details.