Individual History

The Individual History module has been introduced to meet CCHIT requirements. For more information on Therap's CCHIT Compliance Plan, please refer to the CCHIT Requirements page.

This module enables users to access and record historical information for Individuals they support. Users can keep track of complaints, history of illness, reviews, status etc. while accessing necessary medical information in one form.

To access this module users need the following Roles assigned to their Caseload:

• Medical Information Edit - Allows a user to view and edit Individual History along with other 'Individual Medical Information' modules.
• Medical Information View - View Individual History forms along with other 'Individual Medical Information' modules.
  
  

Please follow the steps below to access or update Individual History for an Individual:

1. Click on the 'Individual History' link under the 'Individual Medical Information' module on your FirstPage.



2. Select a Program (Site) in the 'Select Program' page, if you have access to more than one Program.



3. Select an Individual in the 'Select Individual' page. This will open the Individual History form for the Individual you have selected.



4. Present Condition

• Information on Vital Signs is automatically populated from the latest Vital Signs form under the Health Tracking module for the Individual.
• Click on the 'Edit Present Condition' button to add information on the Individual's present conditions.
  
  
  
  
• Enter details in each field and click on the 'Save' button to save the information and go back to the Individual History page.
  
  
  
  5. History
• Medical History
  • Click on the 'Add Medical History' button, this will take you the 'Medical History' Page.
    
    
    
    
  • In the 'Medical History' Page select a 'Medical History Type' from the drop down menu and add relevant information and description. Click on the 'Save' button to add this information to the Individual History form.
  • You may add multiple Medical History information.
    
    
    
    
• Other Medical History
  • Click on the 'View' link beside each medical history type to view its details.
    
    
    
    
  • Information for this section is automatically pulled from other modules as listed below:

    History Type	Module
    Immunization History	Immunization under the Health Tracking module
    Allergy History	Allergy Profile under the Individual Medical Information module
    Diagnosis History	Diagnoses List under the Individual Medical Information module
    Infection History	Infection Tracking under the Health Tracking module
    Medication History	Medication History under the Health Tracking module

    
    
    

• Social History
  • To add Social History for the Individual, click on the 'Add Social History' link.
    
    
    
    
  • Select a 'Social History Type' from the drop down menu and add relevant information and description.
  • Click on the Save button to add this information to the Individual History form.
    
    
    
    
• Family History
  • Click on the 'Add Family History' button to open the 'Family History' page for the Individual.
    
    
    
    
  • From the 'Relationship' drop down menu, select a relationship type and add necessary information.
    
    
    
    
• Notes
  • Click on the Add button (e.g. 'Add Annotation') corresponding to each note type to add notes. You may add multiple notes for each note type.
    
    
    
  • Clicking on the 'Add Annotation' button will open the Annotation page.
  • Add notes for annotation and click on the 'Save' button to add the information to the Individual History form.
    
    
    
    
• External Attachment
  • Click on the add button to add an external file.
  • Click on the 'Scan' button to scan and add a document.
    
    
    
    

    For more information on scanning documents, please refer to the Document Scanning user guide.

    
    
    

• Click on the 'Done' button at the bottom of the form to complete updating Individual History