How to Add or Update Patient Medical History

Overview

Keeping a patient's medical history up to date helps your team identify important medical conditions, allergies, and other information that may affect their treatment.

In Core Practice, medical history information is displayed on the patient's profile so that clinicians and staff can quickly review relevant details when accessing the patient's records.

Reception staff should record the patient's medical history when they first attend the clinic and update it whenever their information charges.

Steps

1. Open the patient's profile, then select History.
    
2. Enter or update the patient's medical history information in the available fields.
   
   
   
   Some fields, including Dental cond present, Med cond present, and Allergies present, contain dropdown options.
   • Select the applicable condition from the dropdown list.
   • If the condition is not listed, enter the information in the free-text field provided.
     
      
3. Click Save Changes after making any updates.
   
   
    
4. Return to the patient's profile to view the saved medical history information.
   
   
   
   Allergies and Med Cond are displayed at the top of the patient's profile.
   • Conditions selected from the dropdown list are displayed by name.
   • Custom conditions are represented by an info icon. Hover over the icon to view the recorded information.

Uploading a Completed Medical History Form

If the patient has completed a medical history form, you should also upload the completed form to the patient's file so the original document is available for reference.

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