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Med/Surg History

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In the STD module, the Med/Surg History form is where you document the patient's medical and surgical history. 

On the main menu navigate to History > Med/Surg History.

  • The diagnosis information entered on the Med/Surg History form is saved in OrderConnect. Information for existing diagnoses is retrieved from OrderConnect.
  • Diagnoses entered on the Med/Surg History form will appear in the following places in the STD module.
    • Diagnosis form (Non-STD Diagnosis grid) 
    • Treatment > Meds/Procedures form > Treatment Submission (Diagnosis grid)

Review history

If there is no change in the patient's medical or surgical history, for the Any Change item at the top of the form, select No.

HIV history

  1. For the HIV positive diagnosis item, select Yes if the patient has this diagnosis.
  2. In the HIV Date Diagnosed - Year box, enter the four-digit year.
  3. For the In HIV Primary Care item, select Yes if the patient is receiving this care.
  4. In the Provider Name box, enter the name of the provider responsible for the patient's HIV care.
  5. For the Current ART Treatment item, select Yes if the patient is receiving this treatment.
  6. On the toolbar above the menu, click the Save icon .

Add diagnosis history 

  1. Below the Diagnosis History panel, click Add Entry.
  2. In the Search Diagnosis box, either enter all or part of the diagnosis name or all or part of the ICD-9 or ICD-10 code. Click Search.
  3. In the search results, select the diagnosis. The diagnosis will appear in the Selected Diagnosis field.

  1. In the Onset Date box, enter the date. Optionally click the previous and next arrows or click the calendar icon  to select a date. To clear the date, click the X.

Note: To clear the entry and start over, click Reset. To cancel the entry, click Cancel.

  1. Click Save Entry.