This lesson will demonstrate how to document in the Summary Family History field.
Summary Family History Field
The Family History field in the Summary is used to record the patients family medical history.
Placing of the Insertion Point
With a patient chart open and the Summary chart section visible:
- Place the insertion point to the right of the field header.
- Click the mouse to insert the cursor.
If the bold green brackets appear (as shown above), then the field is active and ok to begin entering data.
Documenting Family History for Meaningful Use (Stage 2 Menu Set Objective)
Meaningful Use Stage 2 contained a menu set objective for documenting family history for one or more first-degree relatives using structured data. Below are instructions for documenting family history to meet these requirements; however, MACRA/MIPS requirements, as published in 2017, no longer require the eligible provider to report a numerator and denominator for Family Health History. This requirement may still be necessary for other reporting programs, such as Medicaid Meaningful Use or PCMH reporting.
To document family health history, please follow the instructions detailed below:
- Open the patient's chart and the Summary chart section.
- Insert the Family History pick list into the Family History section of the Summary. To insert this pick list using the shortcut code, type fhmu, then hit the spacebar. The pick list can also be inserted by clicking on the Family History item in the MU Patient Dashboard.
- Click on the Family History pick list.
- Using the SMARText Quick Access, check the appropriate items to indicate the patient's family health history. In order to increase the numerator for this measure, one of the following conditions must be met:
The user must document at least one of the the items from List (1) or one of the items from List (2) plus at least one problem from the condition list.
Family History List (1)
- Father dead
- Father alive and well
- Mother dead
- Mother alive and well
- Brother dead
- Brother alive and well
- Sister dead
- Sister alive and well
- Daughter dead
- Daughter alive and well
- Son dead
- Son alive and well
Family History List (2) - Must also choose at least one problem from the condition list
- Father alive with problems: choose at least one problem from the condition list.
- Mother alive with problems: choose at least one problem from the condition list.
- Brother alive with problems: choose at least one problem from the condition list.
- Sister alive with problems: choose at least one problem from the condition list.
- Daughter alive with problems: choose at least one problem from the condition list.
- Son alive with problems: choose at least one problem from the condition list.
Indicating a Condition for a First Degree Relative
To indicate that a patient's first degree relative has a problem or condition, follow the steps below:
- Click on the Family History - First Degree Relatives pick list.
- Using the SMARText Quick Access, check one of the following items: Father alive with problems, Mother alive with problems, Brother alive with problems, Sister alive with problems, Daughter alive with problems, Son alive with problems.
- Click on the alive with problems pick list.
- Using the SMARText Quick Access, check all problems or conditions that apply.
Other Family History (Outside of Meaningful Use Requirements)
Family history for non first degree relatives will be entered into the Family History chart section as well, however this does not need to be in a structured format. Non First degree relative family history will not calculate for the Meaningful Use measure.
To enter the Starter Pick List for Family History, Type the shortcut code fam- into the Family History field then press the spacebar.
The Family History Starter Pick List will expand to include the information shown above. The Family History Starter Pick List should be used as a guide. It may not contain all the items used while charting and will not increase the numerator for the MU Stage 2 requirement.
*Note: The first time this pick list is used, it must be downloaded from the SOAPware Cloud Library. To download the pick list, type fam-"into the Family History field and press Shift + F11 on the keyboard. Double-click on the appropriate item in the search results window to download the Pick List to the database.
Choosing Items from the Family History Pick List
In SOAPware, text that appears Blue and Underlined indicates that a Pick List is attached to the SMARText Item.
To select items from a Pick List:
- Click on top of the item (ie: "Positive family history for").
- A list of items will appear in the SMARText Quick Access dialog. Users should place a check box in the Selected field next to each of the items that he/she wishes to insert into the Family History field
Attaching an Item Comment to Family History
To attach a free text comment to the SMARText item:
- Click on top of the SMARText item (ie: Asthma - see above).
- Begin typing desired comments (ie: Mother, as shown above). An Item Comment box will appear for the user to type in.
- Click the Save button.
The item comment will be inserted next to the SMARText item.