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 his 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 in two sections: Past Medical History and Transition of Care section. Reconciliation is done for 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 list of ailments. Select required ailments to be added as part of Medical History.

Past Medical History (PMH) section

Existing/All drop-down list: Displays either the existing Problems/ailments present in 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: The 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 for the PMH section

Del: The option when selected on a particular row would delete that particular row of details, On save.

Add Ailments : Displays the problem list entered by the user explicitly (typically in the first visit), and the ICD Name + Code of ailments diagnosed in subsequent visits; click on the button to add the ailments by selecting from the list on the Add Problems popup. On 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 invoked which displays 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 on this button to select required ICD/SNOMED from the Problem Codes popup list. On 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: The option when selected marks the encounter as no reconciliation done in the encounter.

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

 Since When Date: Either manual entry of date is made or a particular date is selected date from the 'Since When' calendar. The field accepts any text and is a non-mandatory field. This need not be an exact date. Jan 2000 is alright. If row is auto Generated (eg. 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
Doctor can change the status of any problem by selecting from the list box.

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

•  The following table lists out these sources and its description:

Source Description
CCD The drug has been imported in the system through CCD file.
OldPMH The problems added through [+] button from ‘Transition of Care' section and selected with Value as OLDPMH. To be used when client is new to PrognoCIS and old data is transferred.
MedHistory Drug has been added from the ‘Medication History' popup.
Assessment

On Assessment when ICD is added with the MH (add to medical history) option as selected.

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

Severity: Select the severity of the ailment. Following are the values available in the dropdown list:
  • Mild
  • Mild to moderate
  • Moderate
  • Moderate to severe
  • Severe
  • Fatal
Problem Control: Select the current status of the Problem whether it is in control or not. The selected value would be sent in the NAMCS (National Ambulatory Medical Care Survey) Health care survey type of CCD. Following are the standard options available in the dropdown list:
  • Moderately controlled
  • Well controlled
  • Existing worse
  • Slightly controlled
  • Uncontrolled
Reconcile: The drop-down list by default displays 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 onwards.
The Del checkbox is disabled for the problems imported through CCD.
The Reconciliation drop-down list by default displays value, ‘Add’ for problems added via Ailments [+]/ICD [+] whereas it displays value, ‘Select’ for problems imported via CCD.
To add problems or ailments to the patient’s current problem list from Transition of Care section, User has to select the Reconciliation action as ‘Add’ on the problem. To remove problems from Transition of Care section, 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 then that entry is removed from Transition of Care section. On CCD file import for a problem, the SNOMED and ICD code (optional) are available. In PrognoCIS the ICD code is displayed under Code column thus if ICD was not available in hte CCD file then the column displays blank value and the SNOMED code is available as tooltip on the problem name.

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

 Edu icon : The Patient Education icon when clicked invokes Patient Education popup; the material displayed is sourced from Medline Plus. Based on Patient’s preferred language, the Medlineplus Education material is displayed in that respective language. The User has option to either take print of the material and give patient print copies or send the same as email to patients.

Notes: Any special notes regarding patient's past medical history is added in the Notes field. An icon below the Notes label, on click, opens a pop up displaying a larger area for entering notes. Click OK to save the entered notes and close the pop up. The notes now appear in the Notes text area of the main PMH screen. Also, there is a provision for adding predefined phrases in the notes area by clicking on the icon and selecting the desired phrases.

Note:

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

  1. Diagnosed Ailment (ICD Code/Name) does not exist in this list. A new entry is auto- generated, 'Since When' is set to Encounter date and 'Status' to Existing.
  2. Problem exists and Status is 'Not Recovered' then a new entry is not generated.
  3. Problem exists and Status is 'Recovered'then a new entry is auto-generated, with 'Since When' set to Encounter date and Status to 'Existing Recurring'.

Problems are marked as duplicate based on following criteria each:

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

User has to choose a problem from the Duplicate popup; the chosen problem is added /updated in the PMH list whereas the remaining drugs are marked as deleted.

save button: On click saves the details.

close button: On click closes the PMH screen.

history button: On click 'PMH History' popup displays the trace or log history of medication added and/or modified by User.

print button: On click prints the clinic details as header followed by the patient details and the patient's past medical history details.