Enter the Family History
Q: How do I enter the family history?
1. Open the Patient Chart
Open the patient's chart using the Chart Rack.
2. Open the Summary
Click the Summary tab to view the patient's Summary.
*Note: If the Summary tab is not visible in the chart, open it using the Chart Navigator.
3. Place Cursor
To begin entering information into the field, click on top of or next to the Family History field header. When the bold green brackets appear (as shown above), the field is active and ok to begin entering data.
4. Document 1st Degree Relative Family History for Meaningful Use
Stage 2 contains a menu set objective for documenting family history for one or more first-degree relatives using structured data. To document to meet this Meaningful Use measure, type "fhmu" into the Family History field, then press the Spacebar.
- 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.
5. Other Family History Pick List (Non-Meaningful Use)
Family history for non first degree relatives can 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.
Click on one of the available pick lists (ex: click on Positive family history for - ). A list of common diagnosis will appear in the SMARText Quick Access window.
*Note: If the pick list is not entered into your Family History field, type "fam-", then press Shift + F11 on the keyboard. Double click on the item named -(Starter - Family History - Summary), with a shortcut code of Fam-, to insert it.
6. Select Family History from SMARText Quick Access
Place a check mark in the Selected box next to each diagnosis that needs to be entered into the patient's family history.
7. Remove Unused Items
To remove the unused pick lists, right click on the Family History field header, then select Remove Unused Items.