The Medical tab has been enhanced to better meet your CAC needs and to allow CACs to limit access 

to an alleged victim’s/client’s complete medical information as required by HIPAA. 


Viewing Medical Tab Details


To access the full details of a person’s medical information via the Medical tab, you have to go to 

the Session Log/Appointments section and click on Edit on one of the session logs. You should have 

at least View privileges for the Medical Details section to be able to see these information.


Figure 1. Edit button on the Session Log/Appointments table


This will open the Edit dialog box for the selected session. The View Historic Data button will 

show data previously from the Details window, which was seldom used.


Figure 2. “View Historic” button


The data shown in this page used to be the information displayed on the Medical Session Log Details 

popup in the legacy system. The Summary, Sexual Abuse Diagnosis, Physical Abuse Diagnosis, and 

Procedures pages will now show read only data as any data from the old system will be transferred 

here only for viewing and will not be editable.


Figure 3. Medical session log tabs


Description of Medical Data


Below is a description of the data that would be recorded in these tabs if a case had any:


•  Summary Tab – Data Fields are provided to record the overview of the exam including any 

    disclosures made to the provider before, during or after the exam.

•  Sexual Abuse Diagnosis Tab – Record key information about sexual abuse exam.

•  Physical Abuse Diagnosis Tab – Record key information about physical abuse exam

•  Procedures Tab – Record all tests, procedures, screenings, and other relevant details applicable 

    to the exam.


You can click on the “Back to Medical General” button to return to the main Medical tab.


Figure 4. “Back to Medical General” button



Viewing Medical Subtabs


To access the different subtabs for the Medical tab and see the complete information on the medical 

evaluation, click on the “View Details” button:


Figure 5. “View Details” button


You will be redirected to a new page with the following tabs: H&PI, Past Med HX, Fam/Soc HX, ROS, 

Physical Exam, GE, AE, Labs, Dg Impression, Tx-Recs, Clinical Images and FDI. You will be at the 

H&PI tab by default.


Description of Medical Subtabs


  • H&PI (History and Past Illness) --- This is a new page containing all new fields.
  • Past Med HX (Past Medical History) --- This page contains fields from the old H&PI and 
  • Development tabs plus 12 new fields.
  • Fam/Soc HX (Family and Social History) --- This page contains some fields from the old H&PI tab plus 11 new fields.
  • ROS (Review of Systems) --- This page contains fields from the old ROS tab plus 13 new fields.
  • Physical Exam --- This tab contains fields from the previous Vitals and Physical Exam tabs plus 2 additional fields.
  • GE (Genital Exam) --- This tab is similar to the existing tab with 5 additional fields for females and 1 additional field for males. The fields in this tab varies depending on the gender of the alleged victim/client.
  • AE (Anal Exam) --- This tab has the same fields as before plus 3 additional fields.
  • Labs --- This page contains mostly data from the old Follow Up tab plus 11 new fields.
  • Dg Impression (Diagnostic Impression) --- This page is the old IDI (Initial Diagnostic Impression) tab with 1 additional field.
  • Tx-Recs (Treatment Recommendations) --- This page contains some follow up data plus 11 new fields.
  • Clinical Images --- This page will contain just the Document Upload section for clinical images.
  • FDI (Final Diagnostic Impression) --- This page will contain read only data and basically just display old data from the legacy system.
  • Strangulation --- This page has been added 
  • Physical Abuse --- This page has been added


Figure 6. Medical Detail Tabs


Document Upload


All of the subtabs will contain the Document Upload section at the bottom of the page. Any files 

you upload in one subtab will be visible in all subtabs. See the Document Upload help file for 

detailed information on this section.

Figure 6. Document Upload table


NOTE: NCA does not recommend the storage of evidentiary documents as part of this case record. Any 

copies of evidentiary materials should be retained by the appropriate law enforcement and 

prosecution partners.