Diagnosis & Medical History
This article will cover how to diagnose and add new conditions, edit, delete and change the status of conditions in a patient's medical history, and how to include conditions in patient summaries.
How Do I Add a New Diagnosis?
From the Today's Notes tab, click on Diagnosis.
Click the Search Field to look up the name of the medical condition.
Type the First Few Letters in the search field to reveal a drop-down list of the closest matches. Click to select the Condition.
*NOTE Medirecords has implemented SNOMED CT-AU standards for all clinical coding including the diagnosis module.
If you cannot find the condition you are looking for, just type in the name of the patient's condition or symptoms. You do not need to make a selection from the list.
Complete the rest of the form with all the required details, and click Save.
The newly created condition will now be logged in the current consult and added to the patient's Medical History.
How Do I Access a Patient's 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 from a patient record and click Medical History
To quickly filter old or inactive medical conditions from the summary, click Filter to reveal a drop-down list, and select Active or Inactive.
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.
To Add a New Medical Condition, click New Condition to open the new medical condition form.
Click the Search Field to look up the name of the medical condition.
Type the First Few Letters in the search field to reveal a drop-down list of the closest matches. Click to select the Condition.
*NOTE Medirecords has implemented SNOMED CT-AU standards for all clinical coding including the diagnosis module.
If you cannot find the condition you are looking for, just type in the name of the patient's condition or symptoms. You do not need to make a selection from the list.
Complete the rest of the form with all the required details, and click Save.
The newly created condition will now be visible in the summary on the Medical History page.
To Open a Condition, hover your mouse over the name of the condition. When the mouse cursor changes to a Finger Pointer, click the Name of the condition.
To Edit a Condition, click the Tick-box next to the name to reveal a list of options. Click Edit to edit the condition.
Update the form with all the required details, and click Save to apply the changes.
To Delete a Condition, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the condition.
Click Yes to acknowledge the condition will be deleted.
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.
Click Yes to acknowledge the conditions will be deleted.
To Change the Status of a Condition, click the Tick-box next to the name to reveal a list of options. 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. 
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 Include 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.
A Patient Summary is a medical document used for sharing patient information between medical professionals.
You've completed another MediRecords Tutorial. You should now be able to diagnose and update a patient's medical history. If this is not what you're looking for, head back to our knowledge base and search for another article.
For urgent assistance, please contact MediRecords support on 1300 103 903 during business hours.