Overview

The Medical History Summary must be completed at least every 3 years.  Updates may happen more frequently as required by medical appointments and other requirements.  The initial form should be completed during the admissions process to verify client immunization status and any obstacles to care.

Applicable Staff

Creation of the Medical History Summary form is restricted to the ID Nurse.  All ID staff can view the form.

Usage

The Medical History Summary form is client and episode based and can be accessed through the Home View, from within a client's chart, or through menu path Avatar CWS/Mercy Modeled Clinical Forms/Mercy ID Forms/Medical History Summary MIDS.  Select the desired Client and Episode to open the form.

Medical History Summary Section

The Medical History Summary section requires the date of the review, and captures other general information about the client such as hair/eye color, Advanced Directive Status, and various contacts.  Click the blue Submit button at any time to save and close the form.

Overview Section

The Overview Section captures the level of retardation, motor skills, chronic medical conditions that may impact care or participation in treatment, and living arrangements.

Developmental History Section

This section records details of the client’s gestation and birth, developmental milestones, disease etiology, childhood diseases, and family social description.

Medical History

The Medical History Section contains details of the status of all major organ systems.

Medical History Continued:

Psychiatric/Behavioral History Section

This section includes information such as past psychiatric diagnoses, medications used, past interventions and results, and tobacco/alcohol/other drug usage.

Psych/Behavioral History Continued:

Immunizations/Screening Section

Hepatitis Status and immunizations, and Tuberculosis testing and results are captured in this section.

Allergies/Meds/Sensitivities Section

Any allergies and contraindicated medications or sensitivities can be entered here.  New allergies and sensitivities that will be shown in the Client Data Bar and available to other forms can be entered by using the links in the sidebar.  Enter current health status and current medications if known.

Click the blue Submit button at any time to save and close the form. 

Tips & FAQ

Selections can be cleared by pressing F5 on your keyboard.

Using the Allergies and/or Diagnosis links in the sidebar will open new forms to enter information.  Only information entered in this way will be available to other forms or displayed in the Client Data Bar.

Technical Information

Menu Location (Avatar CWS/Mercy Modeled Clinical Forms/Mercy ID Forms/Medical History Summary MIDS)

SQL Table(s) - SYSTEM.medical_history_summary_MIDS

RAD Envelope (if applicable)

Related Forms and Reports -Allergies and Hypersensitivities, Diagnosis