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Clinical Profile: Record Patient Medical History

Last Updated: Jun 19, 2019 10:12AM PDT

Clinical Profile

The Clinical Profile is the left-hand panel that appears in every patient's chart. It’s home to important patient details including their History. The Clinical Profile is always accessible when navigating the patient’s chart and can be edited by any user. It’s designed to support seamless collaboration and documentation as you move through your patient workflow.

Add your patient's allergies
 
You can utilize the allergy section to document structured information about your patient's allergies. The reaction code and severity sections will allow you to specify important details about those allergies.
 
The reaction code is an optional field that allows providers to enter structured data about the type of allergic reaction that occurs for the allergen, ingredient or drug listed. The code itself is in the SNOMED-CT (Systematized Nomenclature of Medicine — Clinical Terms) format. SNOMED is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information. There is only a subset of SNOMED codes that apply to allergic reactions.
 
The “Severity” field is a required field that gives everyone four options to select when documenting an allergy for a patient: null, mild, moderate and severe. Since this field was never required in the past, Elation defaulted all allergies to “null”. In order to ensure accuracy, please review the allergy information section with your patients and adjust the severity level as needed. To view the allergy information:
  1. Go to the clinical profile
  2. Click “Actions” -> “Edit” next to each allergy
  3. Adjust the severity level as needed

Add your patient’s history details

The History section of the Clinical Profile is organized into distinct subsections to help you easily populate and reference details about your patient:

  • Past medical history (PMH)
  • Past surgical history (PSH)
  • Family health history (FH)
  • Social history (SH)
  • Cognitive status (Cogn)
  • Functional status (Func)
  • Psychological status (Psych)
  • Habits
  • Diet
  • Exercise (Exc)

Details within each section can be recorded in free-text or a structured manner.

Free-text Fields:

Free-text fields are fully customizable and allow you to personalize how you document details for the patient.  

  1. Click on the text-field in which you’d like to add information. The field will turn yellow.
  2. Type the details for your patient and click “Enter” on your keyboard to save.
  3. If you’d like to revise text that has already been saved, click directly on the text and the field will turn yellow again to allow for edits.
  4. If you’d like to rearrange the order of your free-text fields, click and drag the text and drop it in the appropriate order.


Structured Text Fields:

Structured text fields include a short pick-list of possible responses to a question. Examples include Education Level and Alcohol Use.

  1. To add a structured question, click on the “Add Special” dropdown menu to the right of the section heading and click the question’s name
  2. The question will appear as a new line-item in the history section. Click on the “Select an answer” dropdown to the right of the question and select the patient’s response
  3. To change the response, click on the dropdown arrow again and select a different option.  


 

Structured Screening Questionnaires

Elation’s built-in questionnaires allow you to easily document responses and calculate the score for common screenings. Our screenings include:

Social:

Psych:

Habits:


To add a screening to your patient’s Clinical Profile, click on the “Add Special” dropdown menu to the right of the section heading and click the screening’s name.
  • The screening will appear as a new line-item in the patient’s history. Next to its name, click on “Open Form”
  • A pop-up window will appear with the questionnaire. Upon completing the questionnaire, the total score for each questionnaire will be calculated.
  • Click away from the pop-up window to save and close the screening. The total score will then appear in the patient’s History.
  • To administer a screening a subsequent time, click on the patient’s score for the screening in the History section. The questionnaire will reappear in a pop-up window and allow you to make updates.
To document multiple screening scores for the same patient:
  • Export the first screening score to your visit note
  • From the visit note, click "Add <clinical profile section>" and the first screening score with the date will be added back into the history section as a separate line
  • To record a second score, complete the screening again

Exposure to Violence (HARK)


Social Connection (NHANES)



Depression (PHQ-2)



Depression (PHQ-9)


Alcohol Use (AUDIT-C)

 

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