Medical History: Family History

The following topics are discussed on this page. Use the links to jump to the desired subject:

The Family History page provides a tool to display and add or edit the patient's family medical history. To sort the list, select Problem, Relative Name, or Relative Type in the Sort field. Each item in the list contains the following option buttons to the right of the entry:

	Show Details: Click this button to show additional details regarding the problem/relative including IDC10 codes and description.
	Add (only available when using the Problem sort option): Click this button to add another relative to this problem. The Add Relative box is displayed. Select the Existing Relative (if applicable), Relative Type, Reason, and Other Reason (if needed). Then, click Save and Close.
	Edit button: Click to edit a problem. See To edit a problem.
	Remove button: Click to remove a problem from the problem list. See To remove a problem.
	View Change Log button: Click to view the details of the problem and any changes. See To view the Change Log. To return to the Family History List, click Back.

To document No Known Family History

If the patient has no known family history to document, you can select the No Known Family History option. The No Known Family History fly over box is displayed. Enter the Source and Verified Date information. Then, click Save.

To add a Problem

To add a problem to the list, select the Add Problem button. The Add Problem box is displayed.
In the Problem field, you can enter the problem in free text or you can select a problem from the database (SNOMED-CT or ICD10). To select a problem from the database, begin typing part of the problem description. (In this field, you can also type in the ICD10 code. When an ICD10 codes is selected, the ICD10 code and SNOMED code are both displayed in the Details of the problem.) A list of possible matches appears as you type. You can continue typing to narrow down the list. Highlight and select the desired problem. The text in the bracket is the search text; The text after the brackets is the actual description of the item selected. [See Also: Using the SNOMED-CT database] Note: If an item does not contain a SNOMED code, it will be marked as incomplete.

The condensed items are identified in Medical Records > Master Files > Diagnosis Codes > Available on Condensed Search check box.

If applicable, enter additional comments in the Notes field.
In the Relative Type field, use the drop-down to select the relative type that has been diagnosed with the problem. As you select the relative, additional fields are displayed.
Enter the First Name and Last Name of the relative.
Enter the Estimated Age at Onset indicating when the problem first started for the relative.
Enter the Estimated Birth date/year for the relative.
Select the Gender of the relative.
Click Save and Close. Or, click Save and Add More if you have additional problems to enter.

To manage relatives

The Manage Relatives button allows you to access a list of relatives and make edits, as desired. Click Manage Relatives. The list of relatives is displayed. To make changes, click the Edit button.

To document that Family History is Unknown

When Family History is unknown for a particular family member, you can select that from the Add Problem window. Follow the steps identified in To add a Problem except in the Problem field, type the SNOMED code 407559004 or type "family history unknown" to locate the SNOMED code and select it. Then, select the Relative that the unknown status relates to and click Save.

To generate the CCD (Continuity of Care Document)

The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information. This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click Generate CCD.

To verify Family History (No Change)

The No Change option allows you to indicate that you have reviewed and verified that the Family History is correct and hasn't changed since the last assessment/review.

Click No Change located at the upper corner of the window.
A message box is displayed with the message, Would you like to mark all family problems as being reviewed and verified? Select Yes to indicate you have reviewed and verified the family problem list, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the date and time displayed in the Last Reviewed field (top left corner of the page) is updated.

To edit a problem

1. Click next to the problem you want to edit. The Edit Problem box is displayed. Edit any of the fields as needed. See To add a problem above for field descriptions.
2. In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.
3. Click Save to save your changes and return to the family history list, or click Close if you want to cancel your changes.

To remove a problem

1. 1. Click next to the problem you want to remove. The Remove Problem box is displayed.
  2. In the Reason field, use the drop-down list to select a reason for removing the problem. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.
  3. Click Remove to continue. You are returned to the problem list with the problem now removed.

To view the change log

1. A change log is available to view all details of a problem change. The log records when a problem is added, edited, or removed, and contains the login name of who made the change, a reason for the change, and both the original and new values of the problem description, chronicity, notes, occurred date, and resolved date.
2. There are two ways to access the change log:
  - Click View Change Log at the top of the screen to view changes to all family medical history items.
  - Click the button next to a particular problem to view changes for only that one problem.
3. On the Family History Change Log page, items are displayed according to the date/time they were changed, with the most recent change first. You can alter your view to display only added, edited, or removed problems, as well as, sort the problems by description. To change your view, use the drop-down lists in the Filter and Sort fields to select your desired view options. Once selected, the list is resorted accordingly.
4. The default view allows you to view a quick list of problem changes showing only the date/time, user, family history item, and action (added, edited, or removed). Click the show details icon next to a particular problem to display additional details for that item. Click Show All Details to display additional details for all the item changes.
5. Click Back to leave the change log and return to the Family History list.