---
title: How to Document General Medical History
description: Guide nurses through the complete documentation of a patient's general medical history during screening.
---
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December 24, 2025
# How to Document General Medical History
**Audience:** Nurses
**Purpose:** Guide nurses through the complete documentation of a patient's general medical history during screening.
### When to Perform This Step
This step is part of the **screening process** and is a **Healthcare Authority requirement**.
Each patient must have their medical history fully documented in the EMR at least once.
It is persistent across visits and can be updated as needed.
### Accessing the General Medical History Form
1. **Log into Helix** as a nurse
2. In the **Today’s Admissions** section, click **“Screening”** next to the patient’s service
3. Once the screening window opens, scroll to the **General Medical History** section
### Sections to Complete
> All history sections can be expanded using the coloured buttons (green/red) next to each title.
> If a patient has **no history**, click the **minus (-) button**, confirm, and ensure the word **“None”** appears.
#### Adding Medical History
Selecting No History
#### Diabetes
- Click the **red button** next to “Diabetes”
- Toggle the switch **on** if the patient has diabetes
- Select:
- **Type** (Type 1, Type 2, etc.)
- **Number of years**
- **Control status** (controlled, uncontrolled, unknown)
- **Additional notes**
- Click **Save**
---
#### Hypertension
- Follow the same steps as for Diabetes
- Select number of years and control status
- Click **Save**
---
#### Allergies
- Click the **green button** next to “Allergies”
- For each allergy:
- Select **type**, **allergen**, **severity**, and **details**
- Click **Submit**
- To remove all allergies, click the **Minus (-)** button and confirm
---
#### Past Medical History (Systemic Conditions)
- Click the **green button** next to “Systemic”
- Select from the **ICD-10 diagnosis list**
- Add number of years
- Click **Submit**
- Repeat for multiple conditions
- Use Minus (-) button to indicate no systemic history
---
#### Past Surgical History
- Click the **green button** next to “Past Surgeries”
- Choose a surgery from the list
- Enter years since surgery; system will calculate approximate date
- Adjust **day/month** if needed
- Add notes and **Submit**
- Repeat as needed
- Use Minus (-) button if no surgical history
---
#### Family History
- Click the **green button** next to “Family History”
- Select known conditions from the list
- Click **Submit**
- Repeat or use Minus (-) button to indicate none
---
#### Social Habits
- Click the **green button** next to “Social Habits”
- Fill in as applicable
- Submit and repeat as needed
- Use Minus (-) button if no social history applies
---
#### Current Medication
- Click the **green button** next to “Current Medication”
- Choose medications from the system list
- Add notes if applicable
- Submit
- Use Minus (-) if patient is not on any medication
---
#### Other Relevant History
- Enter any additional free-text medical history as needed
### Notes & Functionality
- **Persistent Record:** This section is saved permanently in the patient’s chart. You do **not** need to re-enter it every visit.
- **Dynamic Updates:** Time-based fields (e.g. “2 years diabetic”) are automatically incremented by Helix over time.
- **Search Tips:**
- If an allergy or surgery is missing from the list, use **“Other”** and write details manually
- For custom entries, you may use **“Add Item”** in relevant dropdowns
### Compliance Reminder
All sections must be reviewed and documented per regulation.
Ensure accuracy and completeness. If unsure, ask the patient or flag for doctor review.
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