Medical History & Condition Management: Quick Guide

Introduction

This article provides a step-by-step guide to managing a patient’s Medical History within MediRecords. You will learn how to view and search Medical Conditions, add new Diagnoses from Today’s Notes, edit or delete existing Conditions, and update their status. The article also explains how to include or exclude conditions from Patient Summaries, ensuring that clinical information is accurate, up to date, and shared appropriately across care teams.

Contents

1. Viewing the Medical History
2. Adding a Diagnosis from Today's Notes
3. Editing a Condition
4. Deleting a Condition
5. Condition Status
6. Including or Preventing Conditions in Summaries

Viewing the Medical History

The Medical History page in a patient's clinical record displays a summary of the patient's Medical Conditions, their Severity, and their Status.

Click on the Clinical tab within a patient record and then select Medical History.

To search for a medical condition, click the Search Box, and type in the first few letters of the name. Press Enter and the system will display a list of the closest matches of conditions belonging to that patient.

Adding a Diagnosis from Today's Notes

1. From the Today's Notes tab within a patient file, click on Diagnosis.
   
    
2. Click the Search Field to look up the name of the medical condition.
   
    

3. Type the First Few Letters in the search field to reveal a drop-down list of the closest matches. Click to select the Condition. You can also submit free text by typing the condition and then hitting enter on the keyboard.

   *NOTE: Medirecords has implemented SNOMED CT-AU standards for all clinical coding including the diagnosis module.
   
   
    

4. Complete the rest of the form with all the required details and click Save.
   
    

5. The newly created condition will now be recorded in the current consult and added to the patient's Medical History.

   

Editing a Condition

1. To open a condition, hover your mouse over the condition name until it becomes underlined, then click the condition name.
   
    
2. Alternatively, you can click the tickbox next to the name to reveal a list of options. Click Edit to edit the condition.
    
3. Update the form with all the required details and click Save to apply the changes.

Deleting a Condition

1. To delete a Condition, click the tick-box next to the name to reveal a list of options.
2. Click Delete to permanently delete the condition.
   
   
    
3. Click Yes to acknowledge the condition will be deleted.
   
    
4. To delete multiple Conditions at once, click the tick-boxes next to the names to reveal a list of options. Click Delete to permanently delete the conditions.
5. Click Yes to acknowledge the conditions will be deleted.

Condition Status

If a patient is no longer struggling with the Condition, you may update the Status to Inactive to indicate it is not a current problem. If the patient is currently facing the Condition then Active Status is most appropriate. 

1. To change the Status of a Condition, click the tick-box next to the name to reveal a list of options.
2. Click Status to reveal a drop-down list and click Activate or Deactivate.
   *NOTE: To Activate a condition that has been Deactivated, you will need to use the Filter to switch to the list of Inactive conditions. 
   
    
3. To Change the Status of Multiple Conditions at Once, click the Tick-boxes next to the names to reveal a list of options. Click Status to reveal a drop-down list and click Activate or Deactivate.

To quickly filter old or inactive medical conditions from view click Filter to reveal a drop-down list, and select Active or Inactive.

Including or Preventing Conditions in Summaries

To Include or exclude a Condition in the Patient Summary, click the Tick box next to the name to reveal a list of options. Click More to reveal a drop-down and click Include in Summaries/Exclude from Summaries.

A Patient Summary is a medical document used for sharing patient information between medical professionals.