Recording Patient History Information

This section explains how to record patient history information in ExamWRITER. Topics include the following:

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Patient History check box under the ALL OK heading to record that there are no exceptions to the patient’s healthy medical systems.
    Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.

  4. Click Process or right-click anywhere in the Patient History window.

    The Patient History window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Deselect check boxes, if necessary, or click the appropriate button at the bottom of the window to reset or deselect the patient history ALL OK check boxes or add custom text.
    • If you click UNSelect All, all patient history ALL OK check boxes are deselected.
    • If you click Reset, all patient history ALL OK check boxes are selected.
  6. Click Process.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Medical/Surgical/Ocular check box.
    Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.
  4. Click Process or right-click anywhere in the Patient History window.

    The Medical History window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Select the Medical Hx, Ocular Hx, Systemic Surgery, or Ocular Surgery option to record history associated with those areas.
  6. Select the appropriate text in the field on the left of the window.
    • To create and maintain keywords, place your cursor in the Search field and press F12.
    • To search for keywords, enter text in the Search field.
    • To add custom text, select the appropriate check boxes, click Custom Text, enter the text, and select the Include Timeline check box to include time line information.
    • To clear selections, click Clear.
  7. If necessary, select an eye from the Eye drop-down list.
  8. If necessary, select dates from the Timeline drop-down lists.
  9. Click Saves.
  10. Repeat steps 6–9 as necessary until all history information is saved in the table at the bottom of the window and click Process when finished.

    In the table at the bottom of the window:

    • To discontinue an item, select it and click Discontinue Item.

    • To delete an item, select it and click Delete Item.

    • To delete all items, click Delete All.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.
  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Medications - Systemic/Ocular/Allergies [MU] check box.
    Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.
  4. Click Process or right-click anywhere in the Patient History window.

    The Patient Systemic Medications and Allergies [MU] window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Select the Systemic, Ocular, or Online Brand and Generic Search (ExamWRITER ePrescribing Interface users only) radio button to search for and record history associated with those areas.
    (ExamWRITER ePrescribing Interface users only) If you choose to search for brand and generic medications online, you have access to an expanded list of medications and can add more medication details to the patient's record. The strength, generic name, form, route, NDC ID, quantity, and RxNorm code are included as part of the medication details and are saved in the patient's record. Adding medications to the patient's record by using this process improves your integration with the ExamWRITER ePrescribing interface because the same medication details are in the interface. Although you can modify other medication details that you add from the online search, you cannot modify the strength and route of medications with NDC IDs.
  6. To search for a medication, begin entering it in the Name Search field and then click Search.
    • To search for unknown medications, click Unknown Medications.
    • To add or edit medications, right-click on the medication or click Add/Edit Medication. For more information, see Maintaining Medication & Allergen Information
    • If the patient is not taking any medications, click the appropriate No Medications button to add the text “No reported medications” to the table at the bottom of the window.
  7. Double-click the medication name in the table at the top of the window to add it to the patient's medication list at the bottom of the window.
  8. If you are participating in the CMS Physician Quality Reporting System (PQRS), record medication verification by selecting one of the following radio buttons:
    • Meds Documented. This autocodes G8427, indicating that you met the performance measure.
    • Meds Not Documented. This autocodes G8428, indicating that you did not meet the performance measure.
    • Incomplete List
    • Not Eligible. This autocodes G8430, indicating an exception to meeting the measure.

    The PQRS procedure code associated with your selection is recorded in the Diagnosis/Procedure Coding window on the Procedures tab. For more information, see To select procedure codes.

  9. To record a medication as discontinued, select the medication in the table at the bottom of the window, click Discontinue medication, select a date from the Discontinue Date calendar, and click Save.

    The medication’s status is marked as discontinued and it is removed from the list of medications. To unmark a medication as being discontinued, see Viewing & Refilling Prescriptions.

  10. To note that a patient is allergic to a medication, select the Allergy check box next to the medication in the table at the bottom of the window, select as many reactions as necessary, select an onset date from the Onset calendar, and click OK.
    If patient has no medication allergies, click No Medication Allergies to add the text “No known medication allergies” and a check box in the Allergy column to the table at the bottom of the window.
  11. To document that a medication:
    • reconciliation was performed, click Medication Reconciliation.
    • allergy reconciliation was performed, click Medication Allergy Reconciliation.
  12. To delete a medication, select the medication in the table at the bottom of the window, click Delete medication, and click Yes.
  13. Click Save/Exit.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Allergens - Non Medication check box.
    Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.
  4. Click Process or right-click anywhere in the Patient History window.

    The Patient Allergens window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Double-click the allergen name in the table at the top of the window.
    • To search for a specific allergen, begin entering it in the Name Search text box.
    • To add or edit allergens, right-click on the allergen or click Add/Edit Allergen. For information, see Maintaining Medication & Allergen Information
    • If a patient has no known allergens, click No known Allergens to add the text “No known non-medication allergens” to the table in the bottom of the window.
  6. If you are participating in the CMS Physician Quality Reporting System (PQRS), record medication verification by selecting one of the following radio buttons:
    • Verified Medications
    • Meds listed, not verified
    • Incomplete list
    • Not available to verify

    The PQRS procedure code associated with your selection is recorded in the Diagnosis/Procedure Coding window on the Procedures tab. For more information, see To select procedure codes.

  7. To record an allergen as discontinued, select the allergen in the table at the bottom of the window, click Discontinue allergen, select a date from the Discontinue Date calendar, and click Save.

    The allergen’s status is marked as discontinued, and it is removed from the list of allergens. To unmark an allergen as being discontinued, see Viewing & Refilling Prescriptions.

  8. To document that a medication reconciliation was performed, and to help your practice meet meaningful use criteria, click Transition of Care Medication Reconciliation [MU].
  9. To delete an allergen, select the allergen in the table at the bottom of the window, click Delete allergen, and click Yes.
  10. Click Save/Exit.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Family Ocular check box.
    Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.
  4. Click Process or right-click anywhere in the Patient History window.

    The Ocular Family History window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Select the Ocular or Systemic radio button to record family history associated with those areas.
  6. Select the appropriate text in the field on the left side of the window.
    • To create and maintain keywords, place your cursor in the Search field and press F12.
    • To search for keywords, enter text in the Search field.
    • To add custom text, select the appropriate check boxes, click Custom Text, enter the text, and select the Include Timeline check box to include time line information.
    • To clear selections, click Clear.
  7. Select a family member from the Family Members box.
  8. If necessary, select an eye from the Eye drop-down list.
  9. Select dates from the Timeline drop-down lists and click Save Item.
  10. Repeat those steps as necessary until all family history information is saved in the table at the bottom of the window and click Process when finished.

    In the table at the bottom of the window:

    • To discontinue an item, select it and click Discontinue Item.

    • To delete an item, select it and click Delete Item.

    • To delete all items, click Delete All.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Social [MU] check box.

    • Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.

    • Green text signifies that the item is associated with a PQRS procedure code or a MIPS measure.

  4. Click Process or right-click anywhere in the Patient History window.

    The Social History window opens. If a Current Information window opens, click the appropriate button at the bottom of the window to change, add, reselect, or delete the previously entered text.

  5. Record the patient’s smoking status by selecting the check box at the top of the window or the options in the Tobacco Use [MU] box. If the patient is a smoker, you must select the patient’s tobacco use and either the Counseling Intervention Recommended or Pharmaceutical Intervention Recommended check box to meet meaningful use criteria.
  6. Record the patient’s alcohol use, cannabis (marijuana) use, narcotic use, sexually transmitted disease status, blood transfusion status, and birth order.
  7. (Optional) Enter text in the Custom Text field.
    • To delete an item saved in the Social History Reported box at the bottom of the window, select it and click Remove Item.
    • To delete all items saved in the Social History Reported box at the bottom of the window, click Clear All.
  8. Click Process.

  1. In the ExamWRITER chart window, click the Patient Hx – ROS tab.

  2. Click the Patient History bar.

    The Patient History window opens.

  3. Select the Developmental, Spectacles, Contacts, Low Vision, Reviewed [MU], Disposition, and Orientation check boxes.
    • Red text signifies that the corresponding check box was previously selected and information relating to that text was previously recorded.
    • Blue text is a heading for the black or red text below it.
    • To record medication reconciliation to meet meaningful use criteria, select the Reviewed [MU] check box.

  4. Click Process or right-click anywhere in the Patient History window.

    5. Depending on the boxes that you checked, various windows open with additional options.

  5. Select or deselect the appropriate check boxes, and click Process.

    • To record selected information for the right, left, or both eyes, click OD, OS, or OU, and then select the appropriate check boxes for the right, left, or both eyes.

    • To add custom text, select the appropriate check boxes, click Custom Text, enter the text, and click OK.

    • To clear previous selections on the form, click Reset Form.

    • If a Current Information window opens, click the appropriate button at the bottom of the window to add, edit, save, redo, or delete the previously entered text.