Medical History

This page guides you through the creation and management of Medical History records for the client

These are the topics on this page

Introduction

The Medical History profile allows the organisation to maintain a comprehensive medical history of the client. Medical History records can be initially created when the client comes into service with the organisation and then periodically or when there are changes to the clients health.

The information collected even though not mandatory helps the organisation to understand and appreciate the client’s medical and health conditions, and it can contribute to goal setting, plan reviews and effective communication with support staff (through risk alerts thus ensuring the client receives the appropriate support and services and that unmet needs are reduced.

The Medical History profile is accessed through the client record by clicking on the Medical History menu which is located within the vertical menu bar

Navigating the Medical History page

The following is an outline of the generic fields that comprise the Medical History page:

ClientID: This field is used to input the particulars of the Goal that the client would like to achieve.
Diagnosis Physical: This field is used to input a narrative of the diagnosis of the clients physical condition
High Blood Pressure: This field is used to identify if the client has HBP concerns.
Shortness of Breath: This field is used to identify if the client has Breathing concerns.
Heart Pacemaker: This field is used to identify if the client has Pacemaker.
Anaesthetic: This field is used to identify if the client has reaction concerns with Anesthesia.
Heart Disease: This field is used to identify if the client has diagnosed heart disease.
Heart Disease Comments: This field is used to input a narrative of a diagnosed heart condition.
Lung Disease / Asthma: This field is used to identify if the client has a diagnosed lung condition or has asthma.
Tuberculosis (T.B.): This field is used to identify if the client has been diagnosed with tuberculosis.
Lung Disease Comments: This field is used to input a narrative of a diagnosed heart condition.
Liver Disease / Gastro Intestinal: This field is used to identify if the client has been diagnosed with liver disease or GI concerns.
Liver Disease Comments: This field is used to input a narrative of a diagnosed Liver or GI condition.
Diagnosis Mental: This field is used to input a narrative of a diagnosed mental health condition.
Allergies: This field is used to identify if the client has been diagnosed with any allergies.
Allergies Comments: This field is used to input a narrative of any diagnosed allergies.
Cancer Diagnosed: This field is used to identify if the client has been diagnosed with cancer.
Cancer Diagnosed Date: This field is used input the cancer diagnosis date.
Cancer Comments: This field is used to input a narrative of a diagnosed cancer condition.
Kidney Disease: This field is used to identify if the client has been diagnosed with kidney disease.
Kidney Comments: This field is used to input a narrative of a diagnosed kidney disease or condition.
Muscular / Skeletal Problems: This field is used to identify if the client has been diagnosed with musculoskeletal concerns.
Muscular / Skeletal Comments: This field is used to input a narrative of a diagnosed musculoskeletal condition.
Excessive Drinking: This field is used to identify if the client has any excessive drinking concerns.
Smoking: This field is used to identify if the client is a smoker.
Drinking / Smoking Comments: This field is used to input a narrative related with the clients smoking and drinking.
Medical Summary: This field is used to input a narrative of a detailed medical summary of the client general health condition.
Disability: This field is used to input a narrative of the clients disability(ies).
Diabetes: This field is used to identify if the client has a diabetic condition.
Diabetes Comments: This field is used to input a narrative of a diagnosed diabetic condition.
Medication: This field is used to identify if the client is prescribed prescription medications.
Medication Comments: This field is used to input a narrative of a detailed medical summary of the medications taken by the client.
Neurological / Mental Problems: This field is used to identify if the client has a diagnosed psycho-social or neurological condition.
Diagnosed Depression: This field is used to identify if the client has been diagnosed with a depressed state .
Epilepsy: This field is used to identify if the client has been diagnosed with a epilepsy.
Mental Problems but Calm/Alert: This field is used to identify if the client has been diagnosed with a psycho-social problems.
Withdrawn Behaviour: This field is used to identify if the client has been diagnosed with a psycho-social problems..
Aggressive Behaviour: This field is used to identify if the client has been diagnosed with a psycho-social problems.
Diagnosed Dementia / Alzheimer: This field is used to identify if the client has been diagnosed with a neurological disease.
Mental illness Comments: This field is used to input a narrative of a detailed medical summary of the clients neurological, mental and psycho-social health.
Stroke: This field is used to identify if the client has experienced a cerebrovascular accident.
Stroke Date: This field lists the date that the cerebrovascular accident occurred.
Stroke Comments: This field is used to input a narrative of a detailed medical summary of the clients cerebrovascular accident.

The following is an outline of the generic fields that comprise the Medical History page:

Medical Record No: This field is used to input a medical reference number.
Referring Doctor: This field is used to input the particulars of the referring doctor.
Referring Doctor Address: This field is used to input the address particulars of the referring doctor.
Referring Doctor Phone: This field is used to input the referring doctor’s phone number.
Medical Info / Bl.Pressure / Pulse: This field is used to input a narrative of a detailed medical summary of the clients observations.
Admitted From other Facility: This field is used to input a narrative of a previous RACF admission.
Reason for Admission: This field is used to input a narrative as to the reasons for a RACF admission.
Principal Diagnosis: This field is used to input a narrative of the client’s primary diagnosis.
Provisional Diagnosis: This field is used to input a narrative of the client’s principal diagnosis is not known.
Identified Major Procedures: This field is used to input a narrative of the client’s surgical procedures.
Other Procedures: This field is used to input a narrative of the client’s medical and non-surgical procedures.
Cause of Injury: This field is used to input a narrative as to the cause of the clients condition, specifically if its due to an injury.
Medication on Admission: This field is used to input a narrative medication the client had
Flu Vaccination: The date the client received the influenza vaccine
Adverse Effects Antibiotics: This field is used to identify if the client has adverse antibiotic reactions.
Adverse Effects Other Drugs: This field is used to identify if the client has adverse drug reactions.
Pulmonary Embolus: This field is used to identify if the client has had a embolism of the lung.
Deep Venous Thrombosis: This field is used to identify if the client has had DVT.
Bed Sores: This field is used to identify if the client has had or does have pressure injuries.
Wound Hemorrhage / Haematoma: This field is used to identify if the client has experienced wound hemorrhaging.
Wound Infection: This field is used to identify if the client has had or does have wound infections.
Urinary Tract Infection: This field is used to identify if the client has had or does have UTI’s.
Blood Transfusion Reaction: This field is used to identify if the client has had or does have blood transfusion concerns.
General Appearance: This field is used to input a narrative as to the clients general condition.
Skin / Hair Comments: This field is used to input a narrative as to clients skin condition and integrity and hair.
Oral requirements: This field is used to input a narrative as to clients oral health.
Dentures: This field is used to input a narrative as to whether the client has dentures.
Eating / Nutrition Comments: This field is used to input a narrative as to clients hydration and nutrition.
Bladder Assessment: This field is used to input a narrative as to clients voiding and continence.
Bowel Assessment: This field is used to input a narrative as to clients motions and continence.
General Condition: This field is used to input a narrative as to clients general health.
General Assessment Comments: This field is used to input a narrative of the assessment made in relation to the clients health.
Temperature: This field is used to input the observations related with temperature.
Pulse: This field is used to input the observations related with heart rate.
Urinalysis: This field is used to input the observations related with a UA of the client urine.
Blood Pressure: This field is used to input the observations related with BP.
Respiratory Assessment: This field is used to input a narrative as to clients Respiratory assessment.
Circulatory Assessment: This field is used to input a narrative as to clients circulatory assessment.
Cognitive Functioning: This field is used to input a narrative of the clients cognitive assessment.
Muscular Skeletal: This field is used to input a narrative of the clients musculoskeletal assessment.
Gait / Mobility Assessment: This field is used to input a narrative of the clients mobility assessment.
Behaviour Assessment: This field is used to input a narrative of the clients behavioral assessment.

Creating a Medical History Record

To create a Medical History Record observe the following steps

Select the Clients>Clients sub-menu to open the Client List page into the browser.
Search for the Client record from within the Client list.
Highlight the Client record to be edited.
Either click on the edit button or double click on the Client record to open it within the Client page.
Select the Medical History icon from the left vertical menu bar to open the Medical History List page within the browser.
Select New button to open a new Medical History page into the browser
Update the applicable field values that reflect the medical history as reported by the client.
Select the Save button to create the record.
Select the Close button to exit back to the Medical History List page within the browser.

Editing a Medical History Record

To edit a Medical History Record observe the following steps

Refer to steps 1 - 5 as outlined above in Creating a Medical History record.
Highlight and double click the Medical History record to open it within the Medical History page within the browser.
Update the applicable field values that reflect the medical history as reported by the client.
Select the Save button to update the record.
Select the Close button to exit back to the Medical History List page within the browser.

Deleting a Medical History Record

To delete a Medical History record observe the following steps:

Refer to steps 1 - 5 as outlined above in Creating a Medical History record.
Highlight the Medical History record from the Medical History List that is to be deleted.
Select the "Delete Button" in the upper right portion of the window to present a Delete Record pop-up screen.
Select the OK button from the Delete Record pop-up screen, to remove the selected record.

Adjusting the activity status of a Medical History record

To edit the activity status of a medical history record observe the following steps:

Refer to steps 1 - 5 as outlined above in Creating a Medical History record.
Highlight and double click the Medical History record to open it within the Medical History page within the browser.
To deactivate the Medical History record select the Deactivate button.
The Medical History record page will refresh, all fields will be disabled.
To activate the Medical History record select the Activate button.
Once done, you can exit back to the Medical History List.