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Version: 3.1

View the clinical history

Overview​

This flow describes how to review the symptoms and the diagnoses of a patient. Care stores each of them as a condition. You can review the records of the current encounter, or the records of all past encounters.

Pre-requisites​

  • You have the permissions listed below. Without one of them, the encounter shows "You do not have permission to view clinical data for this encounter".
  • You do not need write access. This flow is read-only, and it works for an encounter of any status.

Permissions​

PermissionAccess
Can view clinical data about patientsLets you view the symptoms and the diagnoses of a patient.
Can Read encounter related clinical dataLets you view the symptoms and the diagnoses of an encounter.

By default, doctors, nurses, administrators, and facility administrators can read encounter clinical data. Staff can view patient clinical data.

Steps​

1. Review the records of the current encounter​

  1. Open the encounter.
  2. Go to the Overview tab.
  3. Read the Symptoms section and the Diagnoses section. Both sections show the records of that encounter.

Note: When nothing is recorded, the sections show "No Symptoms" with "No symptoms have been recorded", or "No Diagnoses" with "No Diagnoses have been recorded".

2. Open the full patient history​

  1. Select See Clinical History on the encounter. You can also press the keyboard shortcut h.
  2. The clinical history page of the patient opens. The title of the page shows the name of the patient.

3. Review the past records​

  1. Select the Past Symptoms tab or the Past Diagnoses tab.
  2. The records show grouped by year and then by date, newest first.
  3. Read each record. A record shows the clinical term, badges for Status, Verification, and Severity, the onset date, and who reported it.
  4. Select Show notes to open the note text. Select Hide notes to close the note text.
  5. If the record comes from another encounter, select Go to Encounter to open that encounter.

4. Read the badges​

  • Status values: Active, Recurrence, Relapse, Inactive, Remission, Resolved.
  • Verification values: Unconfirmed, Provisional, Differential, Confirmed, Refuted, Entered in Error.
  • Severity values: Mild, Moderate, Severe.

Note: A user retracted a record with the Verification value Entered in Error. Do not use that record for clinical decisions.

5. Leave the history page​

Select Back to Encounter or Back to Patient.

Expected Outcome​

  • You see the symptoms and the diagnoses of the current encounter in the Overview tab.
  • You see the symptoms and the diagnoses of all past encounters in the Past Symptoms tab and the Past Diagnoses tab.
  • You return to the encounter or to the patient after you finish the review.

Concepts:

Flows: