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Version: 3.1

Record a symptom

Overview​

This flow describes how to record a symptom for a patient during an encounter. Care stores each symptom as a condition.

Pre-requisites​

  • The patient has an open encounter at the facility, and that encounter is the patient's active 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.

Note: Without an active encounter, the screen shows "Symptoms cannot be recorded without an active encounter".

Permissions​

PermissionAccess
Can view clinical data about patientsLets you see the symptoms of the patient.
Can Read encounter related clinical dataLets you see the symptoms of the encounter.
Update Encounter related clinical dataLets you record and change symptoms.

Doctors, nurses, administrators, and facility administrators have the Update Encounter related clinical data permission by default.

Without view access, the encounter shows "You do not have permission to view clinical data for this encounter".

Steps​

1. Open the symptom screen​

Open the encounter. Go to the Overview tab. Find the Symptoms section. Select the edit (pencil) icon.

You can also press the keyboard shortcut s on any encounter screen. The shortcut opens the same symptom screen.

The symptom screen shows the symptoms that the encounter already has.

2. Start a new symptom​

Select Add Symptom. For each further symptom, the control reads Add another Symptom.

A search box opens.

3. Search for the symptom​

Type a minimum of 3 characters. The screen shows a message below the search box that tells you the minimum length.

The results come from a standard SNOMED CT clinical-finding terminology.

The search box has two tabs:

  • Search: the terms that match the text that you type.
  • Starred: the terms that you pinned.

To pin a term, select the star icon on a result.

Note: Your administrator sets the clinical terminology for your deployment. Your administrator can also change it.

4. Select the term​

Select a term. A new row appears with these default values:

ComponentDefault
StatusActive
VerificationConfirmed
SeverityModerate
Onset DateToday

If you select a term that the encounter already has, Care shows the warning "Symptom already exists!". Care does not add a second row.

5. Change the values​

Change the values of the row if you need to.

ComponentOptions
StatusActive, Recurrence, Relapse, Inactive, Remission, Resolved
VerificationUnconfirmed, Provisional, Differential, Confirmed, Refuted
SeverityMild, Moderate, Severe
Onset DateAny date up to today

Note: Care does not accept a future onset date. Care does not offer Entered in Error for a new symptom.

6. Add a note​

To add a note, open the more-options (⋮) menu of the row. Select Add notes. Type the note.

Select Show notes to open the note text. Select Hide notes to close the note text.

7. Add more symptoms​

Repeat from step 2 for each further symptom.

8. Submit​

Select Submit.

Expected Outcome​

  • Care shows the confirmation "Questionnaire submitted successfully".
  • The symptoms appear in the Symptoms section of the encounter Overview tab.
  • The symptoms appear in the Past Symptoms clinical history of the patient.

When the encounter has no symptom, the section shows "No Symptoms" with the message "No symptoms have been recorded".

Concepts:

Flows: