Copying medical conditions or allergies to clinical notes
You can assign medical conditions and allergies to patients in Health History to remind you of and to keep a record of any conditions, illnesses, or allergies your patients may suffer from. For example, you could assign a medical condition to document that a patient experiences excessive bleeding or has diabetes. In the Health History module, you can copy a patient's medical history to the Clinical Notes panel in the Patient Chart.
Important: The HIPAA Privacy Rule established national standards to protect an individual's medical records and other personal health information. The rule applies to health care providers and requires appropriate safeguards to protect personal health information and sets limits and conditions on the uses and disclosures that health care providers may make of such information without a patient's authorization.
To copy a medical condition or allergy to a clinical note
1. In any module except the Office Journal and eDex, click File, point to Switch To, and then click Health History.
The Health History window appears.
2. In the toolbar, click Copy to Clinical Note.
The selected patient's health history is copied to Clinical Notes in the Patient Chart.