Introduction to the Hx/Meds Tab
The Hx/Meds Tab is where a patient’s current medications, medication allergies, and medical history are all recorded. These are recorded using several tables each with their own category. On the left side of the tab there is also a series of drop downs called the review of systems. We will go through each of these tables one by one.
Medications
The Medications table is in the lower left corner of the tab. You can add entries using the three dot ellipsis in the upper left corner of the table. New entries will be added to the bottom of the list. These entries do not have to be perfect because they will be refined later on in New Crop and then reverse synchronized. What is most importance is getting the name of the medication and the dosage if the patient can remember it. If a patient has stopped a medication you can right click on the medication and select “mark a medication as stopped with today’s date”. This will add today’s date to the right of the medication in the “stop” column. This must have at least one entry even if it is “No meds” (which is selected by pressing the “no meds” button to the left on the table).
Allergies
The Medication Allergies table is in the lower right corner of the tab. Entries are added just like medications. This must have at least one entry, even if it is NKDA (No Known Drug Allergies)
Surgical History
This table is used to enter past eye surgeries such as lasik, cataract sx, blepharoplasty, etc. Add an entry using the three dot ellipsis, and enter as much information about the surgery as the patient can remember. This does not need to have an entry if the patient reports no previous eye surgeries.
This is the window that pops up when you add an eye surgery entry. As you can see, this patient only remembered the type of surgery, the year of the surgery, and which eyes underwent surgery.
Tobacco Use
The Tobacco use table is in the middle of the tab. To use this table there are two options. Using the three dot ellipsis, the first two options that appear at the top are Tobacco use with a 3x3 grid of blocks to the left and Add with a plus sign to the left. Add will allow you to free type an item and search, but the easier way to add an entry is by using the grid entry option. This will open up a window with the most commonly used entries for a given table to select from. You simply put a check in the “yes” column for the entry you wish to select and then click save. This must have some entry, even if it is “never a smoker”
This is what using the grid entry function looks like. Simply click yes next to the item you wish to enter; leave unchecked all items you do not wish entered, then click save.
Social/Other
The Social/Other table is in the middle left of the tab. Here, we want to know the patient’s current drinking status and recreational drug status. This table functions just like the Tobacco Use table and it is easiest to use the grid entry option. This must have one entry each for Drinking Status and Recreational Drug Status.
Family
The Family table is on the upper right of the tab and is where we enter pertinent family history of ocular or systemic disease. For eye disease, the primary diagnoses to check for in family history are Glaucoma, Macular Degeneration, and Retinal Detachments (These three diseases must have an entry checked either yes or no). For systemic disease, the primary diagnoses to check for are Diabetes and Hypertension. All of these will be accessible using the grid entry option; all other pertinent family history will need to be found using the add function.
Past Medical
The past medical table is on the top middle of the tab and here we record all of the patient’s medical conditions both past and present to the best of their recollection. Common conditions such as diabetes, hypertension, high cholesterol, migraines, thyroid disorder, seasonal allergies, etc can be added using the grid entry function. All other conditions will need to be found using the add function. This must have at least one entry even if it is “no medical issues reported”.
Ocular
This table is in the upper left of the tab and is a compilation of the patient’s past and present eye conditions. Add common conditions using the grid entry function, all other conditions will have to found using the add function. This must have an entry checked either yes or no for glaucoma, amblyopia, hx of eye trauma, flashes, and floaters.
Review of Systems (ROS)
The review of systems is a table of drop downs that is used to record all current conditions/symptoms that a patient has, organized according to bodily system (cardiovascular, respiratory, musculoskeletal, etc). It also distinguishes current conditions/symptoms from past conditions/symptoms. In this, it differs from the past medical table which records current and past conditions. This is illustrated in the example below. Here you have hypertension listed in the past medical, but not in the review or systems. The patient at their exam on 12/9/20 reported that they had been diagnosed with hypertension; at this time, hypertension would have been recorded in both the past medical table as well as the review of systems (under cardiovascular). Returning the following year for their exam on 2/20/21, they reported that due to changes in diet and exercise, their doctor told them that they no longer needed to be watched for hypertension. The OA would then remove hypertension from the cardiovascular drop down in ROS (because it is no longer a current condition), but leave it checked “yes” in the past medical table.
To populate negatives for all fields in the ROS for new patients (rather than free typing them all) click on the three dot ellipses in the upper left of the ROS table and select “comprehensive ROS”
This will open up a new window where you can enter findings in all of the different systems. Left click on the grey area to the left of the dropdowns and select “encounter favorites”.
This will open another window. Check “PVC Normal ROS” and click ok.
This will autopopulate negatives in all the fields; however they will not display on the main page unless you click in the cardiovascular dropdown (no need to enter anything) and then click save.
All of the ROS fields and negatives will now display in the ROS box which can be free-typed in now if there are any changes to the patient’s conditions. This will also populate the Mental Assessment categories in the middle of the Hx/Meds tab which can be adjusted if the patient appears to be disoriented or if their mood and affect seems off.
If the patient is established then simply right click on any of the grey areas outside of one of the tables and select “forward from last value” to forward both the previous ROS and mental assessment categories.
Here is a spread sheet of examples for Review of Systems:
If a patient answered negative to all of these questions this is what the tab should look like:
This would be an example of how you would review medications and medical history for an established patient (using the examples above):
Now we are going to review medical history starting with medications. Last time you were in the medications were had listed were Lisinopril, Celexa, and Baby Aspirin? . . . Any others? . . .
For medication allergies we had listed Latex and Sulfates? . . . Any others?
We had you listed as don’t smoke, no drug use, and drink socially?
For Family history of eye disease we had macular degeneration listed?
And you previously had Lasik surgery?
Next we will complete a review of systems. Please let me know anything past or present that you have been monitored by your doctor for each system, starting with . . .
Consitution like recent weight loss? . . .
Under Cardiovascular we have a history of hypertension listed, but not currently? . . .
Ear, nose, mouth, throat like sinus problems? . . .
Respiratory like asthma? . . .
Gastrointestinal like acid reflux? . . .
Genitourinary (jen-ih-toe-urinary) like kidney stones? . . .
Musculoskeletal like arthritis? . . .
Integumentary (in-teg-yoo-ment-ary) like eczema? . . .
Neurological like headaches or migraines? . . .
Psychiatric like anxiety or depression? . . .
Endocrine like diabetes? . . .
Hematologic/lymphatic like high cholesterol? . . .
Allergic like seasonal allergies? . . .”
You will notice that past medical is reviewed at the same time as ROS to save time since they cover similar items. Also for an established patient we do not review the Ocular history because this will be reviewed separately near the end of the workup.
Here is a video that shows how to enter all of this into the chart.
Complete the Checkpoint Quiz
e