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Version: 3.1

How to record a symptom

Overview​

This flow describes how to record a symptom for a patient during an encounter. A symptom is one kind of condition in Care.

Pre-requisites​

  • The patient is registered in Care.
  • The patient has an encounter that is open. You cannot record a symptom in an encounter that is completed, cancelled, discontinued, or marked as entered in error.
  • You are a member of the facility that owns the encounter.
  • You have the permissions listed below.

Permissions​

PermissionAccess
Update Encounter related clinical dataLets you add, change, and remove symptoms in an encounter.
Can view clinical data about patientsLets you see the symptoms that the care team already recorded.

Steps​

1. Open the encounter​

  1. Open the facility.
  2. Find the patient, and open the encounter.

2. Open the symptom form​

  1. Select Encounter Actions.
  2. Select Add Symptom.

You can press s instead, while you view the encounter. The s shortcut opens the same symptom form.

3. Select the symptom​

  1. Select Add Symptom in the form.
  2. Enter the name of the symptom in the search box.
  3. Select the symptom from the list of results.

Care shows a warning if you select a symptom that the list already contains. Change the existing entry instead of adding a second one.

4. Complete the details​

Set the details of the symptom. Care fills the values in the Default column for you.

ComponentsWhat it capturesDefault
Onset DateThe date the symptom started. You cannot select a date in the future.Today
StatusThe course of the symptom, from Active to Resolved.Active
SeverityHow severe the symptom is: Mild, Moderate, or Severe.Moderate
VerificationHow certain you are about the symptom.Confirmed
NotesFree text about the symptom.Empty

Repeat step 3 and step 4 for each additional symptom.

5. Save the symptoms​

  • Select Submit to save the symptoms to the encounter.
  • Select Save as Draft to keep your entries and finish later.

Expected Outcome​

  • The symptoms show in the Symptoms list on the Overview tab of the encounter.
  • The symptoms show under Past Symptoms in the clinical history of the patient.
  • Care records your name and the date against each symptom.

Concepts:

Flows: