History and Physical

Step by step video guide here:

  1. You must first have the client open, then click the Search icon.
  2. Type “History and Physical” into the search bar.
  3. Click to select “History and Physical (Client)” from the search results.
  4. In the CDAG Program Enrollment window pop-up, click the drop down and click to select the appropriate program.
  5. Click OK to continue.
  6. The History and Physical will open to the General tab. Enter the chief complaint.
    1. If you want to add vitals, click Save.
    2. Then click on the “Open vitals flow sheet” button.
    3. This brings you to the New Entry Flow Sheets screen. Enter the vitals information that you have.
    4. The Flow Sheet also includes key data points, such as smoking status, what smoking cessation interventions the client is on, a pain measurement, medication reconciliation, and fall risk assessment.
    5. When you’ve completed the vitals, click Save, then click on the X to close.
    6. This takes you back to the History and Physical, but now the vitals are included.
  7. Navigate to the History of Present Illness and complete this tab. All sections will pre-populate to “Normal” or the section’s equivalent.
    1. There is a body on which to designate location of issues. Click on the body to open the Skin Image Markup pop-up.
    2. Click on the body to create a dot at the location.
    3. You can change the color and size of the marker by selecting the options in the dropdown menus. The sizes shown below are: Blue = 1x, Black = 2x, Red = 3x.
    4. Use the buttons at the bottom of the pop-up to save what you’ve added (click Update), undo the changes you’ve made since opening this pop-up (click Undo All Changes), or erase all marks (click Reset).
  8. Navigate to the Medical History tab and complete this screen.
    1. Allergies will be automatically pulled from the Rx module. If you need to refresh this, click the “Get Current allergy list” button. To add allergies, see Allergies, Intolerances, Failed Trials.
    2. This tab includes a pain assessment.
    3. This tab also pulls medications and medication history from the Rx module. If you need to refresh this, click the “Get Current Medication List From SmartCare” button.
    4. You can also place orders directly from this screen by clicking on the “Place Order” button. However, any outpatient medication orders should be entered in the Rx module. See Creating a New Order (Prescription).
    5. This tab also includes a diet assessment.
    6. At the end of this tab is a place to enter any Course of Action that needs to be taken.
  9. If you need to update or add a diagnosis, navigate to the Diagnosis tab. This tab works the same as the standalone Diagnosis Document.
    1. To add a diagnosis, search for the diagnosis by either the diagnosis code or by description. You can also select a favorite diagnosis from the dropdown list.
    2. Select the appropriate diagnosis from the search results.
    3. Select the type of diagnosis, whether primary, additional, or provisional.
    4. If needed, you can also add severity, remission, or other specifiers. You can also check the “Rule Out” box if needed.
    5. Once completed, click Insert. This will push the diagnosis to the Diagnosis List area of the screen. You may repeat these steps to add more diagnoses.
  10. Once you’ve completed all tabs, click Sign to complete and generate the document.