Medical History Entries and Structured Data Areas

You can use Add Medical History or Read Term - Add to record any problem description from the Read dictionary (see Add a medical history). You can also add the same medical history entry to groups of patients, within the Patient Groups modules.

A medical history entry is regarded as an entry that does not fit one of the structured data areas:

  • If you use Add-Medical History (Alt-A-L), you will not get a prompt for any SDA (Structured data area). The data, whatever it is, remains as a generalised history entry and is not placed in a SDA.
  • If you use Read Term Add (or Add - Select Read Term), to enter the Read term and press OK, the system will place the record in one of the Structured Data Areas (SDA) if this is appropriate, i.e. Foot Pulse, Exercise, Bronchoscopy, Thyroid disease. If there is no SDA, the record is stored in the generalised Medical History, for example, frozen shoulder, abdominal pain etc. The two exceptions to this rule are the entry of the Read code of C10 Diabetes mellitus, and H33.. Asthma which lead to History-Add rather than a Diabetic or Asthmatic SDA.

For help on using the Read dictionary, see Quick add of Read descriptions from front - Add If there is a choice of more than one SDA, Consultation - Options - Setup governs whether you are offered a list of choose from, or just the Best Fit SDA. See Structured Data Areas.

The advantage of placing data in structured data areas is that you do not have to know which data entry form to use, as the system finds this for you. Another advantage of SDAs is that it makes it easier to find or search for the entry later, either on Summary Forms, or when using Searches / Reports. In any case, the Journal View on Patient Record shows all entries, whether from Medical History or Structured Data Areas.

To make sure terms are placed in relevant SDAs after a History Add entry, read the section on Structured Data Areas.

Add - Select Read Term directly displays the Read Dictionary selection screen. This would be useful for manually entering test results, for example, to enter an alkaline phosphatase, type Alkaline in Keyword, press Enter, double click on the description which best fits the result, and the system automatically displays the Alkaline Phosphatase-Add screen.

Medical Histories can be listed in one of several ways - see List Medical History entries.