EMR User Manual

6.3 Medical Hx

Available sub tabs within this section include: Vitals, Lifestyle, Medical History, Review of Systems, Patient Intake (Add-On Feature).
To customize which tabs populate within this area and populate on your Exam Notes click on the Tools Icon drop-down menu and select 'Exam'. The settings window generates allowing you to select which modules you would like to include.

  1. Vitals: Populate vital findings (Note: Including height and weight will auto-calculate the BMI & assign the related category
  2. Lifestyle: Habits may be documented
  3. Medical History: Pertinent history may be documented
  4. Review of Systems: Checking 'All systems have been reviewed & are normal' will print in reports
    1. You can choose specific categories for all 'WNL' (within normal limits) or you can check applicable boxes for findings
    2. You can also use 'All other systems have been reviewed & are normal' and this will apply normal findings to all other items (other than the systems where findings were noted)
  5. Patient Intakes (Add-On Feature): Custom questions from your online intake forms once completed will populate a snap shot within this area

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