When you complete this module, you will be able to use the History tab to enter:
• Patient information (complaints, allergies, current medications and past medical history)
• Symptoms
• Injury information, such as mechanism, cause of and intent of (high level)
• PQRST / LOTARP (pain assessment)
• Social and family history
• Alerts
Key Point: The first section is complaints. Chief Complaint is a required field.
In addition to Chief Complaint, you can create more entries for secondary or other complaints.
There’s a lot of information that can be entered in the History tab.
Key Point: You’ll always enter:
• Chief complaint
• Allergies (or none)
• Current medications (or none)
As you learned in Navigation Part 2: Entering Data, pertinent negatives are used to indicate that a question has been asked of the patient and the answer was “no.” Use these when that information is pertinent to the PCR.
There are two fields available for allergies:
• Drug Allergies
• Environmental / Food Allergies
You’ll create a new entry for each allergy, then select from the pick list and add details.
Key Point: You can add allergies that aren’t on the list. These will display for the open PCR only.
The allergies section makes use of:
• Pertinent negatives
• Options at the top of the list to be used when you can’t obtain information, or if it’s in another chart.
o No known allergies
o Refer to chart
o Unknown
Key Point: Current medications is the same type of screen as Allergies.
• You can search for medications using generic or brand names.
• You can add medications that aren’t on the list. These will display for the open PCR only.
Options at the top of the list can be used when you can’t obtain information, or if it’s in another chart.
• Refer to chart
• None
• Unknown
• Refused
Key Point: For each medication, you can add details as shown on the screen below.
Key Point: For each relevant item in the patient’s medical history, you’ll select from the pick lists.
• If unable to find the item you need, use Other and add details.
• Past Medical History also uses pertinent negatives.
You’ll enter symptoms / pertinent negatives using pick lists, adding details and viewing on a summary
The symptoms pick lists are divided into categories :
• General
• Respiratory
• Cardiovascular
• Neurological
• Eye / ear / nose / throat
• Pain
• Gastrointestinal / genitourinary
• Obstetric and gynecology
• Musculoskeletal
• Mental health
• Metabolic
Key Point: The Injury screen is used to enter information regarding the injury and related information (general, cause and intent), rather than the specifics of the injury. Injury specifics are entered in the Assess / Tx tab, using the Anatomical images. For more information, see the module Assess / Tx: Anatomical
The PQRST / LOTARP screen is where you can complete a pain assessment.
PQRST / LOTARP allows you to make entries for:
• Origin of pain / symptom
• Onset (times, activity, character)
• Provocation
• Quality
• Radiation
• Severity (numeric and visual scale)
• Relieved by
Social and Family History allows you to make entries for:
• Family disease history
• Accommodation (the patient’s housing situation, recent overseas travel, and other
• Care Giver
• Activities of Daily Living
Use the Alerts screen to enter alerts regarding the patient, for the protection of the patient or for the protection of staff at the receiving facility. The information appears near the top of the printed reports.
Siren Spellcheck: Whenever you’re entering text, if you make a spelling error, Siren will display your text in red to draw your attention to it so that you can correct it.
• You’ll always enter chief complaint, allergies (or none) and current medications (or none)
• You must complete all the fields in the Complaint screen (complaint, type, duration and details).
• Several of the screens in History make use of pertinent negatives.
• There are two fields available for Allergies: drug allergies, and environmental / food allergies
• For Allergies and Medications, if you can’t find what you’re looking for, you can add an item to the pick list for the open PCR.
• The Allergies and Medications pick lists both include options at the top of the list which can used when you aren’t able to obtain information, or if it’s in another chart.
• For current medications, you can search for drugs using generic or brand names