Medical History

Optional module

Available only when Medical History is turned on in Plugins.

Medical History keeps the clinical background clinicians should review before treating a patient: allergies, conditions (diagnoses, surgeries, family history), the medications the patient takes, and complications that happened during visits.

Review allergies yourself

Allergies are recorded for clinicians to review. Meddesk does not automatically check a prescription against the patient’s allergies.

Permissions

Permission	Allows	Starts on these roles
Read medical history	See the Medical tab and complications.	Doctor, Nurse
Create medical history	Add allergies, conditions and medications.	Doctor, Nurse
Update medical history	Edit them.	Doctor, Nurse
Delete medical history	Delete them.	-

The Medical tab

A patient’s record gets a Medical tab, the Medical overview: “Everything to check before treating this patient.” Use Add record to add an Allergy, a Condition or a Medication. The tab has four sections.

Allergies

Field	Meaning
Allergen	What they’re allergic to, for example Penicillin.
Type	Drug, Food, Environmental, Contact or Other.
Severity	None, Low, Moderate, Medium, High or Critical.
Reaction	For example hives, swelling or difficulty breathing.
First observed	When it was first noticed.
Still applies	Turn off if the patient has since tolerated it. It’s then shown as Tolerated.
Notes	Anything else.

The section header counts active and critical allergies.

Medical history (conditions)

Diagnoses, surgeries and family history: Condition (for example Type 2 diabetes), Type (Medical condition, Surgery, Family history, Medication or Allergy), Severity, Description, Diagnosed date, Managed with (for example Metformin), and Ongoing. Turn Ongoing off once the condition has resolved and set the Resolved date.

Medications

Anything the patient takes, prescribed at your clinic or elsewhere: Medication, Dosage, Frequency, Route (for example Oral), Taken for, Prescriber and Prescriber contact, Started, Currently taking (turn off when they stop, and set Stopped), and Notes.

Note

These are the medications the patient takes, for their history. Prescriptions your clinicians write are kept separately by the Prescriptions module.

Complications

Complications raised during appointments, with the appointment, severity, what happened, and who recorded it. They’re added from the appointment itself, not from this tab.

Record a complication during a visit

On an appointment, the Complications section lists what went wrong during that visit.

1. Select Add.
2. Choose the Severity and describe What happened and how it was handled.
3. Select Record.

You see Complication recorded. It also appears on the patient’s Medical tab.

Adding or deleting complications follows the appointment’s clinical rules: allowed while the patient is Checked in, In progress or Awaiting checkout, for the appointment’s clinician and staff with Update or Manage appointments, and after Completed for staff with Update appointments. See Clinical information.

Dashboard and reports

• Dashboard widget: Complications, by severity for a period, with how many were high or critical.
• Report template: Allergy register.
• Data sources: Allergies, Medical history, Patient medications and Complications.

A patient with allergies, conditions or medications on record can’t be deleted until those are removed.