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Version: 3.1

Condition

Definition​

A condition is a clinical problem that the care team records for a patient. Care uses one condition record for two things that clinicians enter separately: a Symptom, which is what the patient reports or the clinician observes, and a Diagnosis, which is what the clinician concludes. A condition is a standing statement about the patient. It stays in the record after the encounter ends, until someone changes its status.

Key Attributes​

ComponentsWhat it captures
Symptom or DiagnosisThe coded clinical finding, selected from the Care terminology list. The clinician cannot type free text here.
StatusHow the condition progresses over time, from Active to Resolved.
VerificationHow certain the care team is about the condition.
SeverityHow severe the condition is: Mild, Moderate, or Severe.
Onset DateThe date the condition started. The date cannot be in the future.
NotesFree text that the clinician adds about the condition.
EncounterThe encounter in which the clinician records the condition. Care attaches the condition to the patient of that encounter.
Recorded byThe user who records the condition, and the date of the record.

Symptom and Diagnosis​

Care keeps symptoms and diagnoses in separate lists, and gives each list its own form.

  • A Symptom is what the patient has. The clinician records a symptom early in the encounter, such as fever or chest pain.
  • A Diagnosis is what the clinician concludes. The clinician records a diagnosis for the encounter, such as pneumonia.

The two lists never mix. A symptom that you record stays under Symptoms, and a diagnosis stays under Diagnoses.

Status​

Status records the course of the condition. Verification records the certainty of the care team. The two are independent: a condition can be Active and still Provisional.

StatusDescription
ActiveThe condition is present now, and the care team manages it.
RecurrenceThe condition returned after a period without symptoms.
RelapseThe condition returned after remission.
InactiveThe condition is not active now, but nobody resolved it.
RemissionThe symptoms decreased, but the condition can return.
ResolvedThe condition cleared.

Verification​

VerificationDescription
UnconfirmedThe care team recorded the condition, but has no evidence yet.
ProvisionalThe condition is a working answer while the care team continues to examine the patient.
DifferentialThe condition is one of the possible answers that the care team examines.
ConfirmedThe care team has enough evidence for the condition.
RefutedThe care team examined the condition and rejected it.
Entered in ErrorA user recorded the condition by mistake. Care keeps the record for audit and hides it from the lists.

A clinician cannot select Entered in Error for a new record. Care sets this verification when the clinician removes a condition that is already saved.