The Surgical History section of the patient profile enables you to record the patient's procedures and surgeries.
💡 Tip: Entering dates for profile items is optional. You can enter partial dates, such as only the year, month and year, or a life stage.
Steps
1. Open the health profile from the patient's chart using one of the following methods:
In the patient dashboard view, click Start/Open > Health Profile.
In the patient summary, expand the desired health profile section.
From an encounter or letter template (see Adding health profile items to an encounter or letter template).
2. Expand the Surgical History profile section.
3. To add a new item, click the +.
4. Fill in the fields, using the following table as reference.
Field | Description |
Procedures
| Select from your diagnostic code library or enter as free text. |
Life stage / Procedure date | Enter a life stage or specific date of the procedure. 💡 Tip: To add a partial date use the YYYY-MM format. |
Risk factor | Select to identify the profile item as a risk. Items selected appear in the list of patient risk factors (see Viewing patient risk factors). |
Notes | Enter any additional information. |
5. Select Additional Fields to expand the data entry form to specify the status (such as resolved or in remission) and the resolution date.
To fold this section select Hide Additional Fields.
📌 Note: When you create a new health data entry or when viewing an entry without any information in the Additional fields section, the section remains closed by default. If any of the additional fields are populated, this section auto-expands when you open the entry.
6. Click Save. The new item is added to the list.
7. To view or edit details about an item, click it.
8. To delete an item, click the trash icon.
9. To view an item's history, click the history icon.
Updated December 20, 2021