How do I complete and update a Client's Medical History?

A Client's Medical History is stored as part of their Care Documentation on the Client's profile. Additional fields will be available for US agencies required to submit 485 forms.

To review a Client's Medical History, navigate to the Client profile and click Care Documentation. Select the Medical History tab.

From here, you can review, complete, and update the various sections of the Client's Medical History (Current Medical History, Past Medical History, Infectious Diseases, Past Surgeries and/or Treatments, Recent Hospitalizations, Immunization History, Allergies, etc.)

Click  to add a row to a section or click  to delete the last row of the section. Or, click  next to the row you wish to delete.

Once you have finished updating the Client's Medical History, click Save at the bottom of the screen to confirm your changes.

Current Medical History, Past Medical History, and Family Medical History

For Current Medical History and Past Medical History, you can add and edit details about the Diagnosis, Treatment, and Start and End Date and select a Primary Diagnosis. You can also indicate whether the Client has a family history of certain conditions in the Family Medical History section. 

If a Client's Medical History is unknown, check the box next to No Known Medical History. 

Infectious Diseases

If the Client has any Infectious Diseases, select the Type and enter the Start and End Dates (if known). If the type of disease is not available in the dropdown, use the Other Infectious Diseases field to describe the disease.

If the Client has not suffered from any Infectious Diseases, check the box next to No Known Infectious Diseases.

Surgeries and Treatments

If the Client has had any Surgeries and/or Treatments, enter the Procedure, relevant Details, and Start and End Dates. If the section does not apply, check the box next to No Known Surgeries.

Hospitalizations

If the Client has been recently hospitalized, enter the Reason and Start and End Dates for the stay. If inapplicable, check the box next to No Known Hospitalizations.

Immunizations

If you wish to include the Client's Immunization History, enter the details of the immunizations (Type, Date, Booster Date) under Has the patient ever been immunized for the following? and Has the patient ever been diagnosed for the following? If the section does not apply, check the box next to No Known Immunizations.

Allergies

If the Client has any Allergies, enter the Name of the Allergy, Type, Severity, Treatment, and Date. If inapplicable, check the box next to No Known Allergies.