Electronic Health Records (EHR)

Documentation Tutorial

Section # 3

The Health History

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Welcome to the Life University Clinic EHR documentation tutorial.

This is a set of lessons for beginning users as well as a reference for those familiar with the

clinic EHR documentation process.

The best way to learn this software is to use this tutorial as a guide as you enter

information in the Life University SmartCloud Training site. In addition to this tutorial, there

are also short videos, FAQs, process flow charts and a Quick Step-by-Step tutorial on the

course Blackboard site.

To get started you will need to enroll in the Life University SmartCloud Training site as

described in Section #1.

This tutorial is a work in progress. Lessons will be added and updated based on your

feedback and as major software updates are released.

Please visit periodically to view the latest updates and new lessons.

In an attempt to address the broad range of users (student interns, faculty clinicians,

administrators, auditors etc.), this tutorial contains clinic procedures, step-by-step

instructions, common errors seen, special tips and key steps and procedures. As a result certain

passages are marked with visual clues so that you can tell at a glance what kind of topic you are

dealing with.

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TABLE OF CONTENTS New Users should follow each section in order

If you are using this as a reference, click on a topic to access it

Page

Access the Patient Electronic Record ...................................................................3

View the Health History Intake Form .....................................................................3

Record the History of Present Illness for each complaint ......................................4

Start a New Note ...................................................................................................4

The Comprehensive Case History ........................................................................5

Using History Logs ................................................................................................5

Verify and Edit Patient History logs .......................................................................6

The Review of Systems .........................................................................................7

Adding a History Log .............................................................................................7

Reason for Care or Current Complaint ..................................................................8

Making Edits to an Incomplete or Pending Note ...................................................8

Add a Problem to the patient’s record ...................................................................8

Add an Introductory Sentence ...............................................................................9

History of Present Illness Narrative .......................................................................9

View the Note ...................................................................................................... 10

Complete the Note .............................................................................................. 10

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Section # 3: The Health History

3.1 Access the Patient’s Electronic Health Record (EHR) A. Click on the Select a Patient icon from the Workspace or the Select Patient button in

the ribbon across the top of the page.

B. Enter your patient’s last name in the search box, select your patient and click OK.

C. Your patient’s name will now appear in the blue highlighted area under the top ribbon.

3.2 View the Patient Health History Intake Form A. Click the EHR Tab in the left column towards the bottom half of the screen

B. Click the Health Records Tab in the left column towards the upper half of the screen

C. Select Health_History_Intake from the list of documents. It will become highlighted

and you can preview it in a thumbnail to the right.

D. Click View Full Screen from the top ribbon

E. Review this form in its entirety to familiarize yourself with the patient’s health status

F. Contact your Faculty Clinician (FC) to review this form as well

If the form is incomplete: the FC will open for pt to make edits

If the form is complete: the FC will click “complete” to populate the comprehensive data

into the patient’s record.

If this form does not appear in the Health Records;

It has not been completed by the patient

3.3 Record the History of Present Illness (HPI)

The HPI includes the facts relevant to the Chief Complaint. This provides the reader full comprehension of the problem(s) and the events surrounding it. This section should clarify and explain each symptom and even include the absence of certain symptoms that are pertinent in the development of a diagnosis. You should also include how the problem interferes with the patient’s Activities of Daily Living (ADL) and any previous care they sought for the problem.

The HPI must include all components of “OPQRST” that you will learn in DIAG 2725 as well as enough information to clarify the problem and the mechanism of injury.

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The Health History Intake form includes a section entitled “Problem Areas”. There

should be a separate Problem Area table for each patient complaint. The intern will

record (hand write) this information on a paper form called the Health History

Worksheet (HHW) as he/she clarifies and expands on the information while interviewing

the patient.

The HHW needs to be reviewed and approved by the Faculty doctor before the patient is

dismissed. The intern will eventually transcribe the HHW notes into a narrative format

in the Complaint Freeform area of the Subjective Speed Note. It must be transcribed

by the intern before the CMR appointment. The completed HHW needs to be scanned

into the patient’s EHR by the staff.

The HPI narrative can be typed directly into the Complaint Freeform area of the

Subjective Speed note as described is section 3.9 this Tutorial.

3.4 Start a New Note A. Click the Documentation tab & Start New Note button in the upper ribbon.

B. Create New Note dialogue box will appear

C. Provider for the Note is the faculty clinician supervising the physical exam

D. Secondary Provider is the Intern

E. Click OK.

Click the drop down arrow and type the first few letters of the doctor’s name who is supervising the visit. Select that doctor by Clicking on their name and then OK.

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The Comprehensive Case History A comprehensive case history includes prior illnesses, symptoms, medications, medical

care, chiropractic care, traumas, surgeries, hospitalizations and specifics about each of

these. It also includes the patient’s present state of health such as exercise habits,

sleep habits, dietary habits, tobacco use and alcohol use. Family history and occupational

histories are also important factors in the patient’s health and are recorded in this

section.

3.5 Enter the Comprehensive portion of the Case History using History Logs

The intern will complete this step during the initial case history immediately after

recording the HPI on the Health History Worksheets. Most of the information from the

Health History Intake form is automatically populated into the patient record with the

exception of the “Problem Areas”. Information that is automatically populated is in the

form of History Logs. The intern will review each History Log with the patient and

clarify and expand upon the information that the patient entered.

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Verify and edit each patient Hx Log and add to note

A. Click the EHR tab in the left column towards the bottom of the page.

B. Click each History Category

C. Double click each History Log

D. Review the information with the patient and add any clarifying

information in each History Log.

E. Do not add information in the Comments box (it is not viewable).

F. Check the “Add to current note” box.

G. Repeat for each History log.

Note

If a patient denies problems

for a History Log you should

Clear the Onset date field

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The Review of Systems (ROS)

On the Health History Intake form the patient was asked about conditions in each of the

body systems. A History Log is created for each system that is denied as well as for

each complaint reported in each system. If the patient incorrectly completes the intake

form and doesn’t click the “none” button” for a system, the intern will have to add a

history log to record that system. Currently Immunological, Psychological and EENT

systems are not asked on the intake form and the intern will need to add a log for each.

The intern needs to review each History Log with the patient and ask further questions

regarding each of the systems.

If the patient denies symptoms in a system;

A. Click the Denied box,

B. clear the Date of Onset

C. Add to current note.

If the patient reports symptoms in a body system

A. Confirm if it is Past or Present

B. Add any clarifying information in the Description or Details boxes

a. This would include; the resolved date, treatment sought, residual

effects and other pertinent information.

C. There are times when you will have to create a New Problem for a Present

condition.

3.6 Adding a History Log There are times when you will have to add a history log to the patient’s record.

Upon interviewing the patient, you may find that they did not include something on the Health

History Intake form or some questions were not asked on the form.

To add a History Log:

A. Click the Add History button in the top ribbon

B. Click on the History category that you want to add

C. Complete the appropriate fields in the dialogue box

You will find that there are several items missing from the HHI form that need to be

added to the patient record: You do that by adding a History log.

Family History for grandparents may need to be added.

ROS: Immunological, Pychological and EENT (Ear, Eye, Nose, throat) may also need to be

added.

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All of the above information needs to be completed with the patient present. The HHW paper form needs to be completed and signed by the Faculty Clinician and the Intern should click the “Complete Note” box in the upper ribbon of the patient EHR.

****The information added below can be entered after the patient is released.****

Reason for Care and/or Chief Complaint This is the reason(s) why the patient is consulting with you today. Commonly there is more than one reason and each “problem” must be a separate entry in the patient health record. In the Electronic Health Record (EHR), the term “problem” relates to the reason for care as well as a health complaint.

3.7 Enter the Patient’s Reason(s) for Care and/or Health Complaint(s)

Making Edits to an incomplete or pending note

If you are resuming this section after closing the program, you will need to select

your patient (section 3.1) and resume the incomplete or pending note by clicking

the number to the right of your name on the blue highlighted bar and then Edit

(see Making Edits to a Note in the FAQs section). I strongly suggest that you

resume the original note for a new patient visit.

Add a “Problem” to the Patient Record A. Click Add Problem from the ribbon at the top of the page

B. Type PC in the Code Search box.

C. Scroll down to find the “problem” that most

closely matches your patient’s “reason for care”.

Click Next in the bottom bar to bring up the

next 15 selections if needed.

D. Do not type anything in the Onset Comments

or Comments box at this time.

E. Be sure to check the

Add to Current Note check box.

F. Click OK.

G. Repeat this for each complaint

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Repeat this for each Complaint, Reason for Care or Current Review of Systems issue.

If you click on the Problem list tab in the upper left, you can see all of the problems you

entered. You can edit each problem by double clicking on it. To verify that the information is

being added or to see what it will look like in the note, click “Note” in the center of the blue

highlighted bar where the patient name is listed.

3.8 Add an Introductory Sentence to the EHR note The Introductory sentence should introduce the patient and the purpose of the visit.

A. Click Documentation in the lower left column.

B. Click Introductory Sentence in the upper left column.

C. Type the introductory sentence for the note in the space provided.

3.9 Type the History of Present Illness narrative The Intern has already interviewed the patient and recorded the History of Present Illness for

each complaint on the paper Health History Worksheets. (see section 3.3)

If you are resuming this section after closing the program, you will need to select your patient

and resume the incomplete or pending note (see Making Edits to a Note in the FAQs section).

A. Click Subjective Speed Note in the upper left column.

B. All of the active problems should appear in the Chief Complaint box. (If they are

not listed, return to the Problem list and add them to the current note.)

C. Click on the first problem (It will appear highlighted) and transcribe the notes

that you recorded on the Health History Worksheet into a narrative format in the

Complaint Freeform area toward the bottom of the page.

D. Repeat this for each “Problem” by clicking on the problem and repeating the

process.

Do not enter anything in

the area above the

Freeform section

for the initial history

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View the Note

As you are working through the History, you can view it at any time by clicking

Note in the highlighted area of the top ribbon. You should view your note often to

see how it will appear in its finalized form.

Complete the Note

When you enter all of the history information and are ready to have your faculty

clinician (FC) review it; click Complete Note.

This will add your signature to the note and mark it as pending.

The note will still be available in your Incomplete Notes basket and

you will still be able to make edits to a pending note.