2. Problem List
To work with the Problem List, select Problem
List from the Lists view and click Edit.
This will bring up the Problem List Administration
window.
In the search bar, type either a problem name or
a diagnosis code.
Checking the box will select the problem and
bring up a box in which to add comments.
After adding your comments, you will be able to
either view the selection details, or add
additional problems, by checking another box.
3. Procedure List
The Procedure List is used to record the
Patients’ surgical history or other medical
procedures.
To edit the Procedure List, select it from
the Lists view and click Edit.
4. Procedure List
To inactivate a Procedure, double click the
check to the left of the Procedure name.
To strike-through an Inactive Procedure,
double click the empty box.
5. Medication List
ePrescribing will automatically update the
Medication List; however, there will be
times where you are required to make a
manual update.
To edit the Medication List, select it from
the Lists view and click Edit.
To add a medication or allergy, click Add.
Choose the date, select the medication or
allergy, the strength, the refills, and the
pharmacy location.
6. Vitals
The Vitals List is used to record a patient’s
height, weight, temperature, and other
vitals.
You can edit the Vitals List either by
selecting it in the List view and clicking
Edit, or by selecting the Vitals element in
the Note Editor.
7. Social History
To edit the Social History, select it from
the Lists view and click Edit.
In order to qualify for Meaningful Use,
Social History items must be selected from
the drop-down menu.
Details can be added in the comments
section.
8. Family History
To edit the Family History, select it from
the Lists view and click Edit.
The Family History can be added as
narrative text or through the drop-down
menu.
9. Medical History
To edit the Medical History, select it from
the Lists view and click Edit.
The Medical History is entirely narrative.
This history can be used to supplement
the Problems and Procedures Lists.
10. Health Maintenance
Health Maintenance is used to record Clinical
Decision Support Rules and Protocols.
Health Maintenance can be edited by selecting it
in the Lists view and clicking Edit.
Rules apply to specific patients; Protocols apply
to all patients.
Rules and Protocols may be set to have pop-up
reminders.