To enter or update family history information:
1. If you haven't already, go to the Fam/Soc History module. To access this module, choose one of these options:
Click Fam/Soc History from the Patient Chart module.
Click the Family History label on the Summary module.
Click Switch to Fam Hx on the Problems module. (Note: Skip to step 5 below.)
Note: You can also display an entry screen for entering Family History items from the OB Record module.
2. To edit an item, you can click the name of the family history condition in the Family History Problem column. Uncoded family history problems are indicated by an “*”.
3. Click Add New from the Family History module. A screen displays the Decision Support problems and also the system-generated list.
4. Click the icon
to the left of a problem to display the decision support for that
particular problem.
5. You can enter Family History problems as either positive or negative. Click POS or NEG to add the problems associated with the patient.
6. You can also click
or the Lookup: click to add items
link to perform a lookup.
7. If you enter a Family History problem that already exists, you will be presented with a duplicate entry warning when you click on POS or NEG. Your options are to continue and edit the existing entry, or cancel the add process.
8. Click the X in the Clear column corresponding to a problem you want to delete from the patient’s Family History.
9. When you click POS for a problem, the Relatives list displays on the right side of the page. Check the boxes for those relatives you want to add to the Family History. Specify the approximate age range for when the problem started (Age of Onset), and indicate whether the relative is living or deceased.
10. You can also click either the
or the Additional Relatives
link if you want to add other relatives (second degree) that are not
listed. Using the drop-down arrows, select the additional relatives
you want to add. Click Add
when done. Repeat for each family member.
11. Type any pertinent comments you have in the Comments text box area. Click Ok when you have identified the appropriate family members for each problem. To return to the Fam/Soc History page without saving any of your changes, click Cancel.
12. If you want to save your work now, click Sign (F10). The LMR indicates the changes that will be saved. Type your key and click Sign.
13. Click Print from the Family History module to print the existing table with its information exactly as it appears on the page.