Table of Contents

1. Form Details
2. Health Problems 1 Tab
3. Health Problems 2 Tab
4. Health Problems 3 Tab
5. Health History 1 Tab
6. Health History 2 Tab
7. Health History 3 Tab
8. Nutrition/Pain Tab
9. Actions by Medical Reviewer Tab
10. Referrals Tab
11. Medical Review Signature Tab 

 

Form Details

• Form Properties
  1. Form Title: NYSCRI Medical History v2
  2. Start from an Existing Form – Yes, if there is a previous version signed and locked.
  3. Copyrighted Form – No
  4. Billable Progress Note – No
  5. Have multiple versions open at same time – No
  6. Open Blank on new version – No
• Required Fields – Yes
• Lookup Tables – None
• Pre-Fill Logic – Yes
  1. Organization Name will prefill from Setup → Program/Billing Defaults → Company Info.
  2. Program Name will prefill from the Program the patient is enrolled in.
  3. Allergies will prefill from ePrescribing.
• Fill to Logic – None
• Signatures
  1. Individual Signature
     • Sig type: Patient
  2. Parent / Guardian Signature
     • Sig type: None
  3. Staff Signature
     • Sig type: Any
     • N/A defaults to unchecked.
     • Route to function.
     • Signature required to lock form.
  4. Medical Reviewer Signature
     • Sig type: Any
     • Route to Function is available.
     • Signature required to lock form (Actions by Medical Reviewer and Referral tabs).

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Health Problems 1 Tab

1. Organization Name will prefill from Program / Billing Defaults.
2. Program Name will prefill from program client is enrolled in.
3. Health problem section: Response is required on each line item.

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Health Problems 2 Tab

1. Health problem section continued: Response is required on each line item.

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Health Problems 3 Tab

1. Health problem section continued: Response is required on each line item.
2. Family History: Required text field.

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Health History 1 Tab

1. Symptom in Past 12 months – Check what is applicable.
2. Immunizations
   • Required section.
   • Grey out – When selecting Not Applicable Immunization selections will grey out.
3. All Immunization Up to Date
   • Required Yes / No selection.

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Health History 2 Tab

1. Family Perception
   
   • Required text field.
2. Hospitalizations
   • Yes / No response required.
   • Grey out – Selecting No will grey out Hospital grid.
3. Active Allergies
   • Prefill – will prefill from ePrescribe.

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Health History 3 Tab

1. Currently Pregnant
   • Yes / No Response required.
   • Grey Out – Selecting No will grey out text field.
2. Receiving Pre-Natal Care
   • Yes / No Response required.
   • Grey Out – Selecting No will grey out text field.
3. Breastfeeding
   • Yes / No Response required.
4. Significant pregnancy history
   • Yes / No Response required.
   • Grey Out – Selecting No will grey out text field.
5. Last Menstrual period
   • Required text field.
6. Last Examination
   • Doctors name / date – Required text field.
7. Height
   • Required text field.
   • If reporting for child:
     • Grey out – Selecting No will grey out text field.
8. Weight
   • Required text field.
   • Weight change
     • Required Yes / No response.
     • Grey out – Selecting No will grey out text field.

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Nutrition/Pain Tab

1. Nutritional Screening
   • Section Required.
   • Grey Out – Selection of No Problem will grey out entire section.
2. Pain Screening
   • Yes / No response required.
   • Grey Out – Selecting No will grey out pain screen selections and text field.
3. Signature Credentials
   • Individual Signature
     • Sig type: Patient
   • Parent / Guardian Signature
     • Sig type: None
   • Staff Signature
     • Sig type: Any
     • N/A defaults to unchecked.
     • Route to function.
     • Signature required to lock form.

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Actions by Medical Reviewer Tab

1. Face to Face
   
   • Yes / No response required.
2. Blood work ordered
   • Yes / No response required.
   • Grey Out – Response of Yes will grey out text field.
3. Other tests
   • Yes / No response required.
   • Grey Out – Response of No will grey out text field.
4. PROS with Clinic
   • Enter vitals, proxy, advanced directive responses.

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Referrals Tab

1. Recommendations / Referrals
   
   • Enter referral information if made.
2. Recommendations shared
   • Yes / No response required.
   • If Yes selected, individual response text field opens.
   • If No selected, how to share text field opens.

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Medical Review Signature Tab

Signature Credentials (see Credentials)

1. Medical Reviewer Signature
   • Sig type: Any
   • Route to Function is available.
   • Signature required to lock form (Actions by Medical Reviewer and Referral tabs).

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