Patient Care Data Entry: Patient Page > History Tab

History Tab Data Entry

The History Tab is dedicated to fields which can be set to Carry from Last Trip in Field Configuration Setup. Carrying from last trip usually takes place when your patient care report is created by selecting an existing patient account. However, some sections of the History Tab contain buttons that will allow you to view data from the last 5 trips with the currently selected patient account to allow you to add that data to your PCR if you did not create your PCR using an existing patient account back in the Patient Care Portal screen. 

The History Tab is split into a few sections:

History Information

This section contains a few miscellaneous fields:

1. Medical History Obtained From (Obtained From) - type of person medical history was obtained from. Select all options that apply.
2. Presence of Emergency Information Form (Emergency Information Form) - indication of the presence of the Emergency Information Form associated with patient's with special healthcare needs. Select Yes/No as applicable.
3. Advanced Directives - the presence of a valid DNR form, living will, or document directing end of life or healthcare treatment decisions. Select all that apply. 
4. Barriers to Patient Care - Indication of whether or not there were any patient-specific barriers to serving the patient at the scene. Select all that apply.
5. Alcohol/Drug Use Indicators - indicators for the potential use of alcohol or drugs by the patient related to the patient's current illness or injury. Select all that apply.
6. Pregnancy - indication of the possibility, by the patient's history, of current pregnancy. This field does not appear on patients indicated as Male.
7. Last Oral Intake - date/time of patient's last oral intake.

Current Medications

This section contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review current medications entered on those reports.

Use the Green Plus Button to add a new medication. Use the Edit/Delete buttons in the Action Column of this section to update or remove Medication records as needed. When adding a medication, make sure to use the Save button to save that medication record, or the Save + button to save the previous medication record and automatically begin to add another medication record.

1. Current Medications (Medication) - the medications the patient currently takes.
   1. Begin typing a medication name to see selection options in the dropdown below. 
   2. Use the red magnifying glass icon (Search Medications) to review medications by first letter if you aren't sure of the spelling. 
   3. If the medication you're trying to add is not available for selection, use the blue 'Add Value Not Listed' button to add it. 
      1. When using this option, enter the medication in the Value box.
      2. Comments can be added as well - when Submit is clicked, your medication will be added to the Current Medications field, and a request will be sent to AIM Support to add that medication to the Current Medications list. 
      3. Note: some medications cannot be added due to various factors. Contact AIM Support for more information if you have questions. Any medication can be listed via the Add Value Not Listed function, and carried to future transports with that patient. 
2. Current Medication Dose (Dosage) - the numeric dose or amount of the patient's current medication.
3. Current Medication Dosage Unit (Unit) - the dosage unit of the patient's current medication.
4. Current Medication Administration Route (Administration Route) - the administration route (po, SQ, etc.) of the patient's current medication. 

Medication Allergies

This section also contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review medication allergies entered on those reports.

Use the Green Plus Button to add a new medication allergy. Use the Edit/Delete buttons in the Action Column of this section to update or remove medication allergy records as needed. When adding a medication allergy, make sure to use the Save button to save that medication allergy record, or the Save + button to save the previous medication allergy record and automatically begin to add another medication allergy record.

1. Begin typing a medication name to see selection options in the dropdown below. 
   1. Keep in mind environmental or food allergies, for example - adhesives, etc, are documented in the section below. This section is strictly for meds the patient is allergic to.
2. Use the red magnifying glass icon (Search Medications) to review medications by first letter if you aren't sure of the spelling. 
3. If the medication you're trying to add is not available for selection, use the blue 'Add Value Not Listed' button to add it. 
   1. When using this option, enter the medication in the Value box.
   2. Comments can be added as well - when Submit is clicked, your medication will be added to the Medication Allergies field, and a request will be sent to AIM Support to add that medication to the Medication Allergies list. 
   3. Note: some medications cannot be added due to various factors. Contact AIM Support for more information if you have questions. Any medication can be listed via the Add Value Not Listed function, and carried to future transports with that patient. 

Environmental/Food Allergies

This section also contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review food or environmental allergies entered on those reports.

Use the Green Plus Button to add a new food or environmental allergy. Use the Edit/Delete buttons in the Action Column of this section to update or remove the food or environmental allergy records as needed. When adding a food or environmental allergy, make sure to use the Save button to save that food or environmental allergy record, or the Save + button to save the previous food or environmental allergy record and automatically begin to add another food or environmental allergy record.

1. Begin typing a food or environmental allergy name to see selection options in the dropdown below. 
2. Use the red T icon (Tier List) to review allergies by category.
3. If the food or environmental allergy you're trying to add is not available for selection, use the blue 'Add Value Not Listed' button to add it. 
   1. When using this option, enter the food or environmental allergy in the Value box.
   2. Comments can be added as well - when Submit is clicked, the food or environmental allergy will be added to the Environmental/Food Allergy field, and a request will be sent to AIM Support to add that medication to the Environmental/Food Allergies list. 

Medical Conditions/Previous Surgeries

This section also contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review past medical history entered on those reports.

Use the Green Plus Button to add a new medical history record. Use the Edit/Delete buttons in the Action Column of this section to update or remove the medical history records as needed. When adding a medical history record, make sure to use the Save button to save that medical history record, or the Save + button to save the previous medical history record and automatically begin to add another medical history record.

1. Begin typing a condition or surgery to see selection options in the dropdown below. 
2. Use the red T icon (Tier List) to review conditions or surgeries by category.
3. If the medical history value you're trying to add is not available for selection, use the blue 'Add Value Not Listed' button to add it. 
   1. When using this option, enter the condition or surgery in the Value box.
   2. Comments can be added as well - when Submit is clicked, the medical history value will be added to the Condition/Surgery field, and a request will be sent to AIM Support to add that medication to the Medical Conditions or Previous Surgeries list. 

Immunizations

This section also contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review immunizations entered on those reports.

Use the Green Plus Button to add a new immunization record. Use the Edit/Delete buttons in the Action Column of this section to update or remove the immunization records as needed. When adding an immunization, make sure to use the Save button to save that record, or the Save + button to save the previous record and automatically begin to add another.

1. Select the Immunization from the dropdown list. 
2. Enter the Year if known.

Practitioners

This section also contains a 'Carry From Previous Trips' button which allows for the user to quickly check the last 5 patient care reports with the patient to review previous Practitioners entered on those reports.

Use the Green Plus Button to add a new Practitioner record. Use the Edit/Delete buttons in the Action Column of this section to update the practitioner records as needed. When adding an practitioner, make sure to use the Save button to save that record, or the Save + button to save the previous record and automatically begin to add another.

Enter the Name of the Practitioner - you can utilize these fields as needed to capture additional information outside of just the name if it will be helpful.

Travel Section

During the COVID-19 Pandemic, several questions regarding the patient's recent travel and/or exposure to infectious disease were added to the patient care report. These fields can be used to track either domestic (within the US) or international travel if relevant to the patient care report you are completing. 

NOTE: Some states continue to track this information, i.e. Georgia, still to this day. Due to state requirements you may still need to confirm this information even if not relevant to the patient's complaint or reason for transport.