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Chart - Medical Area

A patient's medical information, problems, medications, allergies, and tobacco use (optional) are summarized in the medical area of the Chart module (pink area). 

Note: The rows that show in medical area can be customized in Display Fields, ChartPatientInformation.

Double click on a row in the pink area to enter information on the Medical window.  The default tab that opens depends on the row clicked.

Medical Info: Enter general medical information.

  • Print Medical: Print a list of the patient's problems, allergies, medical history, premedicate status (Y/N), medically urgent notes, and medical summary.
  • Premedicate:  If checked and PremedFlag is added to an Appointment View, Premedicate will show in the Chart module medical area (bold red) and in the Appointment box. It will also show when you hover over an appointment if Med Flag is added to the appointment bubble Display Field.
  • Current Meds Documented:  (EHR only).  See Attest that Current Medications are Documented.. 
  • Med Urgent:  Entered text will show in bold red in the Chart module medical area, in the appointment box if Med Note is added to the Appointment View, and when you hover over an appointment if Med Flag is added to the appointment bubble Display Field.
  • Medical Summary:  Entered text will show in the Chart module medical area.
  • Medical History:  This section should always reflect the current medical status. The assistants should type in all items that the patient marks on a medical history form. Once the data is entered into the computer, the dentist can refer to it more easily than the handwritten patient version. There is no archiving or update mechanism, so all changes should also be entered as chart notes. 
  • Service Notes:  Enter useful information that is learned through discussions with patients, such as hobbies, employment, whether they need a blanket or pillow, nervous behavior, whether they are on a strict budget, whether they have to drive a long way to get to the office, etc. Shows in the Chart module medical area.

Problems: Maintain a list of a patient's active and inactive problems. See Patient Problems.

Medications: Maintain a list of the patient's current and discontinued medications. See Patient Medications.

Allergies: Maintain a list of the patient's current and inactive allergies. See Patient Allergies.

Family Health History: Document the health history of a patient's family members. This tab is only visible if EHR is turned on. See Documenting Family Health History.

Vital Signs: Document a patient's pulse, height, weight, and/or blood pressure, and any interventions. This tab is only visible if EHR is turned on. See Documenting Vital Signs.

Tobacco Use: Assess patient smoking status, tobacco use, and document interventions. This tab is only visible if EHR is turned on. See Assessing Tobacco Use and Documenting Interventions.

 

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