Adding a Medical History Entry

As well as being able to view a patient's record from the Journal screen, you can also record new medical history entries.

To record a medical history entry:

Note - If you are recording the first saved entry of this consultation with the patient, the Consultation screen displays. Complete as appropriate, see Consultations for details.
  1. From the Journal screen, select Add journal entry and enter either:
    • A Clinical Code (preceded by #), or
    • A Clinical Term (minimum of two characters)
Training Tip - You can search on multiple words, for example back pain.

  1. Select Search and the matching options display:

    PA_Add_journal_entry

Note - The search does not currently include searching by hierarchy.
  1. Select the term required and the data entry form displays:

    PA_Journal_entry_form

  2. Complete as required:
    • Date - Defaults to today's date, update as required.
    • Priority - Select an appropriate priority for this entry.
      Note - Priorities are a way of allocating an importance to an entry, chronic and serious conditions are usually a Priority 1, and general entries a Priority 3, but this may depending on the practice.
    • Comment - Enter any comments to support this record.
  3. Select Save save to save and close the entry.
See Journal Tab, Editing Entries and Deleting Entries for details.
Note - To print this topic select Print in the top right corner and follow the on-screen prompts.