You can edit the Patient’s Electronic Medical Records (EMR), also known as Electronic Health Records (EHR), under the Notes tab while you are on the call with your patient or when viewing the patient’s Visit page.
Every time a Provider or clinic staff updates the patient’s EMR, a time stamp, and the name of the last person who edited the patient’s records will show appear.
How to Update the Patient's EMR for:
Updating the Patient’s Past Medical History:
1. Click on Edit.
2. Select the condition/s from the dropdown under Other Conditions.
Note: You can select more than one, but one at a time.
3. Click on Add button.
You may also click “No Past Medical History.”
You may click on the trash icon of the condition that you want to remove or is no longer applicable for the patient.
4. Click Done to save changes.
Updating the Patient’s Past Surgeries:
1. Click on Edit.
You may click “No Known Past Surgeries.”
2. Enter the name of the procedure in the blank field.
3. Click on Add button.
4. Click Done to save changes.
Updating the Patient’s Social History:
1. Click on Edit.
2. Select from the dropdown options under Marital status - if the patient is Single, Married, Widowed, Divorced/separated, or In a relationship.
3. Select from the dropdown options under Highest Level of Education - if the patient finished Grammar school, High school or equivalent, Technical/vocational training, College or equivalent, or Postgraduate.
4. Input the patient’s Occupation in the blank field.
5. Input the number of children of the patient in the blank field.
6. Select from the dropdown options under Living situation - if the patient is living Alone, With other people, or with pets.
7. Select from the dropdown options Yes or No if the patient Served in the military.
8. Select from the dropdown options under Legal History - if the patient has history of Charges for violent crime, Jail, Prison, Access to firearms, or N/A.
9. Click Done to save changes.
Updating the Patient’s Health Habits:
1. Click on Edit.
2. Select from the dropdown options: Never, Daily, Weekly, or Monthly for Smoking Frequency, Alcohol Frequency, and Exercise Frequency.
And use the blank field to type in if the patient had any Street Drugs used.
3. Click Done to save changes.
Updating the Patient’s Family History:
1. Click on Edit.
2. Check the checkboxes for those applicable to the patient’s condition.
Conditions listed are Alcoholism, Asthma, Cancer (including skin cancer), Diabetes, High blood pressure, Heart disease, Migraines, Kidney disease/stones, Osteoporosis, Stroke, Thyroid disease, Ulcer disease, Depression, Anxiety, Bipolar, Psychiatrically Hospitalized, and Suicides.
Family options listed are Mother, Father, Siblings, Maternal grandparents, and Paternal grandparents.
3. Click Done to save changes.
Updating the Patient’s Medications:
1. Click on Edit.
You may click “No Known Medications.”
2. Enter the name of the medication in the blank field.
3. Click on Add button.
4. Click Done to save changes.
Updating the Patient’s Allergies:
1. Click on Edit.
You may click “No Known Allergies.”
2. Enter the name of the drug in the blank field.
3. Click on Add button.
4. Click Done to save changes.
All the information added or changes made will be viewable on the Notes tab and saved automatically.
You can also go to the Medical History tab to view the patient’s EMR for Past Medical History, Past Surgeries, Family Medical History, Social History, and Health Habits.
Go to the Allergies tab to view the patient’s list of known medication allergies.
Note: The screenshots above are taken using the new visit page version. To know how to switch to the new version, read: Three Ways to Switch From Old to New Visit Page.
Need more assistance? Send us an email at help@vsee.com or check out the Help section under the Profile Menu of your VSee Clinic.
This article was last updated on: 12 April 2023