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Version: 3.1

Add a symptom or diagnosis from past records

Overview​

This flow describes how to bring the earlier symptoms or diagnoses of a patient into the current encounter. You select the records that you want, instead of searching for each term again. Care stores each of these records as a condition.

Pre-requisites​

  • The patient has an open encounter at the facility, and that encounter is the patient's active encounter.
  • You or a colleague recorded symptoms or diagnoses for the patient in an earlier encounter.
  • The encounter is not Completed, Cancelled, Discontinued, or Entered in Error. In these states, all add and edit controls are read-only.
  • You have the permissions listed below.

Permissions​

PermissionAccess
Can view clinical data about patientsView the symptoms and the diagnoses of the patient.
Can Read encounter related clinical dataView the symptoms and the diagnoses of the encounter.
Update Encounter related clinical dataAdd symptoms and diagnoses to the encounter.

Steps​

1. Open the symptom screen or the diagnosis screen​

Go to the Overview tab of the encounter.

For symptoms, select the edit (pencil) icon in the Symptoms section. You can also press the keyboard shortcut s.

For diagnoses, select the edit (pencil) icon in the Diagnoses section. You can also press the keyboard shortcut d.

2. Open the past records dialog​

Select Symptom History or Diagnosis History.

A dialog opens with the title Past Symptoms or Past Diagnoses. The dialog lists the records of the patient from all encounters. The dialog leaves out the records with the Verification value Entered in Error.

Note: If the patient has nothing to show, the dialog shows "No Records Found".

3. Select the records​

Select the checkbox of each record that you want. The dialog shows the count under Selected.

If the list is longer than one page, select Load More to see more records.

4. Add the records​

Select Add Selected.

To leave the dialog without adding anything, select Cancel.

Care adds the selected records to the list of the current encounter.

5. Review and submit​

Change the Status, the Verification, the Severity, and the Note of each added record if you need to.

Select Submit.

Expected Outcome​

  • Care shows the confirmation "Questionnaire submitted successfully".
  • The added records appear in the Symptoms section or the Diagnoses section of the encounter Overview tab.
  • If you select a term that the encounter already has, Care shows "Symptom already exists!" or "Diagnosis already exists!". Care does not add a second row.

Concepts:

Flows: