Medical history

Use a patient’s Medical tab to review and record medical conditions, associated medications, and vital signs. Conditions and vital-sign records are saved separately.

Before you start

In Patients, open the correct patient and confirm the name in the header. Select Medical. Review existing entries before adding a new record. Use Previous and Next at the bottom of a table when more entries are available.

To add, edit, or delete a record, you also need edit access to the patient and the matching medical action permission.

Enlarge image

Add a medical condition

1. In Medical conditions, select Add condition.
2. Search Condition by name or code, then select the matching diagnosis.
3. Choose a Status: Active, Controlled, Uncontrolled, Improving, Worsening, In remission, Resolved, or Historical.
4. Enter Diagnosis year if known. This field records a year, not a full date.
5. Under Medications, search for and select medications associated with this condition. Remove any selection that does not belong to it.
6. Select Add condition, wait for the Condition added notification, and check the new row.

Enlarge image

Medication selections associate medication names with a condition; they do not create a prescription. For prescribing, see Prescriptions.

If a search offers an option to add a missing diagnosis or medication, you need permission to create entries in the relevant reference list. Use an existing match when possible. For list instructions, see Diagnoses or Medications.

Update or remove a condition

Select a condition’s row to open Edit condition. Update its condition, status, diagnosis year, or associated medications, then select Save and wait for the Condition updated notification.

To remove a condition, select its trash icon at the end of the row. Check the condition named in the Delete condition confirmation, then select Delete. Deletion cannot be undone. If the condition is no longer current, updating its status can preserve its history.

Add vital signs

1. In Vital signs, select Add record.
2. Enter the measurements you have. At least one measurement is required.
3. Check the units for Temperature, Weight, and Height.
4. Confirm Date recorded is the day the measurements were taken. A new record defaults to today’s date.
5. Select Add record, wait for the Vital signs saved notification, and check the saved row.

Enlarge image

BMI appears in the saved table when both height and weight are recorded. It is calculated automatically and is not a separate measurement field.

Vital-sign badges compare readings with the app’s built-in ranges. A green badge means in range; red with an up arrow means high; yellow with a down arrow means low. Elevated blood glucose uses yellow with an up arrow. Badges appear for blood pressure, heart rate, blood glucose, temperature, BMI, and O2 saturation; weight and height have no range badge. These indicators are not a diagnosis; consider the patient’s clinical context.

Edit or delete a vital-sign record

Select an existing row to open Edit vital signs. Correct the measurements or date, then select Save and wait for the Vital signs updated notification. To remove a record, select its trash icon at the end of the row and confirm Delete. Deletion cannot be undone.

If a record will not save

• A condition cannot be added: choose both a condition and status.
• A diagnosis or medication is missing: check the spelling and your reference-list access. Adding a missing entry requires permission for that list.
• Vital signs cannot be saved: provide at least one measurement and a date. Check the field message, blood-pressure format, numeric values, and units. Do not change a measurement just to bypass validation.
• An edit or delete action is unavailable: check your patient edit access and medical action permissions with your admin.
• The section does not load: retry after the connection recovers. A loading error is different from an empty medical history.