Medical records and diagnoses
Series · Health Surveillance · 5 of 7
Consult the worker’s medical history and record diagnoses derived from the medical results.
Essential steps
- Access Medical Records to consult the consolidated medical-occupational history of the worker.
- During the assessment or visit, record the diagnoses using the corresponding button: select the diagnosis and its status (Active and occasional, Active and chronic, or Resolved).
- Review the list of tests with altered results (those that are not “Within normal limits”) as an objective basis for diagnosis.
- Translate the findings into conclusions, medical advice, and restrictions of the examination, which are reflected in the report and certificate.
- Use the Medical Advice Library to standardize recurring recommendations.
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