Editing a Patient’s Medical History

This topic explains how to record the details of the patient’s past medical history and how to mark the patient’s medical history as reviewed.

To edit a patient’s past medical history

1. Open the patient’s Clipboard.

   For more information on opening the Clipboard, go to Accessing the Clipboard.

2. Click the Past Medical History tab.

   A list of medical conditions and surgeries appears.

3. Take the following actions as needed to document the patient's medical history:  
   • If this is an established patient and you have reviewed the patient’s medical history, click Mark as Reviewed.
   • If this is a new patient, click the medical conditions and surgeries that apply to the patient.
   • If you need to add information about the condition or surgery, enter your Notes in the field that appears when you marked the condition or surgery.
   • If you don't see a condition or surgery reported by the patient, Search to add it.
   • If no conditions apply in each section, select None.
4. Click Save.

   Click the chevron in the section heading to collapse the section and view the next one.

   The Show Snomed Codes link allows you to see the SNOMED CT codes that are recorded to the patient's file behind the scenes. These codes are used to facilitate the exchange of patient records between different providers and EHR platforms.

   Want to watch a video tutorial on documenting a patient's history? Check out our series on Documenting Patient Information.