Any user with an edit level of NP/PA or Phys/MD/DO can enter Past medical history (PMH), allergies, medications, and diagnoses into an encounter and can edit the body of the note. They may also enter this information on the patient's Summary page.
Users with a Nurse edit level can enter this information on the patient’s Summary page or within an encounter. However, they cannot enter data into the body of a SOAP note encounter.
Users with a Staff edit level can enter Past Medical History on the Summary page or in an encounter.
Entering information within the patient Summary
1. Open the patient’s chart to the Summary page.
2. Select the (+) or pencil icon to the right of each section to add or edit PMH, allergies, medications, or diagnoses.
Entering information within an encounter
Any user with a Nurse, NP/PA, or Phys/MD/DO edit level can add PMH, allergies, medications, and diagnoses directly within an unsigned encounter.
1. Open an existing encounter or start a new encounter.
2. Scroll through the encounter to find each respective section, or use the Go to... dropdown menu at the top of the note to quickly navigate to a specific section.
3. Select the Record button to the right of each section. A modal window will open to the right, where you can edit or enter information. For detailed instructions on adding a diagnosis, please see: How do I add diagnoses to a patient chart?
4. When recording or editing a diagnosis or medication within an encounter, you can check the box to Attach medication/diagnosis to this encounter to ensure that it is associated with the encounter.
Entering information within the body (S,O, A, P) of an encounter
Any user with an NP/PA or Phys/MD/DO edit level can add PMH, diagnoses, and medications to the body of an encounter.
1. Within the Subjective, Objective, Assessment, or Plan sections, expand the fly-out pane. Select the Previous tab, and click Past medical history. You can add individual or all PMH entries.
2. Within the Assessment section, expand the fly-out pane and select the Diagnoses tab. You can select a diagnosis from your My Dx list, record a new diagnosis, or attach an existing diagnosis to the encounter. For detailed instructions on adding a diagnosis, please see: How do I add ICD-10 diagnoses to a patient chart?
3. Within the Plan section, expand the fly-out pane and select the Medications tab. You can record a new medication, or attach an existing medication to the encounter.