Nursing Assessment - Medical History Section

Record basic medical history information for the selected client.

This information includes allergies, alert information, contagions, and current medications.

Prerequisite:

• A Nursing Assessment has been started for the client.

1. Go to: Avatar CWS > Assessments > Product Assessments > Nursing Assessment > Medical History
2. In the Allergies field, select the client's allergies.
   • If Unknown is selected, the Other Allergies and Allergic Reactions field will become enabled and required.
3. If applicable, in the Other Allergies field, enter any additional allergies.
4. If applicable, in the Allergic Reactions field, enter any associated allergic reactions.
5. in the Last PPD field, select the appropriate result of the test.
   • If Positive or Negative is selected, the Last PPD Date field will become enabled and required.
6. In the Last PPD Date field, select the test date.
7. In the Chest X-Ray field, select the appropriate value.
8. In the Comments field, enter any associated comments.
9. In the Alert Information field, select the applicable alerts.
10. In the If Other, Specify field, enter any additional alerts.
11. If applicable, in the Contagions field, select the client's contagions.
12. If applicable, In the Comments field, enter any associated comments
13. In the Client Taking Medications as Prescribed field, select the client's compliance.
14. In the Current Medications and Dosages, enter the client's current medication and dosage.
15. If applicable, in the Date Last Menstrual Period field, select the date.
16. If applicable, complete the Health Habits, A. D. L., and Summary Sections.
17. Once finished, click Submit.

► Additional Sections

• Nursing Assessment
• Nursing Assessment - Health Habits
• Activities of Daily Living Assessment

► Test Scripts

For implementing new systems or new functionality, download the following standard test script for this feature. Please contact your Netsmart representative for more information about Test scripts.

• myAvatar NX Test Script - CWS - Nursing Assessment .docx