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Medical History Fields

Most fields in this section can be completed without assistance or explanation. Some specialized fields, however, are unique, and several built-in features allow for even faster completion of this section.

The following tips can help you properly and thoroughly complete each subsection in the Medical History section.

Medications & Allergies

Frequency
How often the patient takes the medication. Options for this field include:

  • After Meals – Medication is taken after the patient eats a meal.

  • Before Meals – Medication is taken before the patient eats a meal.

  • BID – Twice (two times) a day.

  • QD – Every day, once a day.

  • QOD – Every other day; once every other day.

  • TID – Three times a day.

Birth History

Gestational Age
How long the newborn was in the mother's womb before being delivered, followed by the unit qualifier for how long the newborn was in the mother's womb before being delivered, such as weeks.

Type of Delivery
How the newborn was delivered and/or the newborn's presentation at birth, such as Limb Presentation.

Color of Amniotic Fluid
Color of the amniotic fluid.

Delivery Complications
Any complications encountered during delivery.

Birth Weight
Weight of the newborn at birth, followed by the unit qualifier for the newborn's weight value, such as lbs.

Placenta Delivery
Whether the placenta was delivered.

Placenta Intact
Whether the placenta was intact when/if it was delivered.

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