Clinical History in Patient Profile

Axxess Palliative Care now provides a Clinical History section on the Health History tab of each patient’s profile. This new section enables users to document patients’ past medical history, past surgical history, social history and palliative history. By maintaining a thorough record of each patient’s clinical history, organizations can optimize patient care, streamline operations and stay compliant.

Clinical History

To document a patient’s clinical history, edit the patient’s profile and navigate to the Health History tab.

Patients tab ➜ Patient Charts ➜ Edit Profile ➜ Health History tab ➜ Clinical History section

To document the patient’s past medical history, navigate to the Past Medical History section and click Add Diagnosis. Enter the diagnosis, start date and resolved date, and click Add. The diagnosis will populate in the table under Past Medical History.

To document the patient’s past surgical history, social history or palliative history, navigate to the respective section on the right side of the screen and enter the necessary information in the text box. Templates can be used in these sections.

To upload documentation of labs, scans or tests, navigate to the Labs section and click Manage Documents.

To upload documents, click Add Documents.

To document the patient’s pediatric history, select the checkbox next to Show Pediatric History Sections. The pediatric fields will appear for completion.

Once all clinical history information has been added to the patient’s profile, click Save at the bottom of the screen. Information saved here will automatically populate in visit notes.

To access the Health History section of a patient’s profile through a visit note, click Edit History in the Clinical History section of the note. During the visit documentation process, once you’ve reviewed the patient’s history, select the checkbox to confirm your review.

A Family History section will be coming soon to the Clinical History section in each patient’s profile.

Updated on 02/09/2023