Create/Edit Patient Clinical Data

Patient Clinical Data comprises five mandatory sections that must always be included in a Patient Summary Health History:

• Allergies and intolerances
• Current problems and diagnoses
• Medical devices (implanted or external)
• Major interventions
• List of current medications

They also include several optional modules, such as:

• Vaccinations
• Problems that no longer exist
• Social history (e.g., smoking, alcohol consumption)
• Pregnancy history (for women)

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  Figure 2.6: Create/Edit Patient Data.

Examples of the Clinical Data Sections

Allergies

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  Figure 2.6: Allergies & Intolerances

Medication Summary

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