Documentation/Clinical

== Clinical domain ==

All documentation pages in the clinical domain — patient records, encounters, observations, conditions, and related concepts.

Concepts

Page	Summary
Concepts/Patient	A person who receives care through your facility or program — the record holds demographic and contact details and anchors all clinical documentation.
Concepts/Encounter	One interaction between a patient and a facility — an outpatient visit, admission, observation stay, emergency visit, virtual consultation, or home visit — grouping everything the care team records.
Concepts/Condition	A clinical problem recorded as a symptom or diagnosis, including status, verification, severity, onset date, and notes.
Concepts/Allergy & Intolerance	A substance that causes a reaction in a patient, with category, criticality, verification, clinical status, occurrence, and notes.
Concepts/Observation
Concepts/Diagnostic Report	The result of a diagnostic service request, grouping observations, a conclusion, notes, and attachments.
Concepts/Service Request	A request for a diagnostic test, procedure, referral, or other service for a patient during an encounter.
Concepts/Specimen	A biological sample collected from a patient for testing as part of a service request.
Concepts/Notes	The space where staff record and exchange written notes about a patient in titled discussions.
Concepts/Consent	A patient's permission or refusal for treatment, research, or sharing information, recorded against an encounter.
Concepts/Questionnaire Response	The record of one submitted form, including its author, submission time, answers, patient, encounter, and status.
Concepts/Care team	The staff who look after a patient during one encounter, with each member's clinical role and one primary member.
Concepts/Files

References

Page	Model	Summary
References/Patient	Patient	Technical reference for the Patient module in Care EMR — models, fields, relationships, and save behaviour.
References/Encounter	Encounter
References/Condition	Condition
References/Allergy Intolerance	AllergyIntolerance
References/Observation	Observation
References/Consent	Consent
References/Notes	Notes
References/Specimen	Specimen
References/Service Request	ServiceRequest
References/Questionnaire Response	QuestionnaireResponse
References/Care team	Encounter	Technical reference for the encounter care team in Care EMR — the JSONField on the Encounter model, its Pydantic specs, and the set_care_team_members write path.

Flows

Page	Summary
Flows/Create a service request	Create a service request from the facility service catalogue during an encounter.
Flows/Upload a file	Upload a file to a patient or encounter from a device, camera, or audio recording.
Flows/Enter diagnostic report results	Create a diagnostic report and enter observation results for a service request.
Flows/Collect a specimen	Record collection details and identify a specimen for a service request.
Flows/Add care team members	Add a facility user to an encounter's care team and assign a clinical role.
Flows/Record a symptom	Record a symptom for a patient during an active encounter.
Flows/Record an allergy	Record a patient's allergy or intolerance during an open encounter.
Flows/Record a consent	Record a patient's consent against an active encounter.
Flows/Create an encounter	Start a clinical encounter for a patient at a facility — from the patient page or from an appointment — and save it.
Flows/Search for a patient	Search for an existing patient in Care before registering a new one — search methods, results, and verification, to prevent duplicate records.
Flows/Start a discussion	Start a titled Clinical Notes discussion for a patient or encounter.
Flows/View questionnaire responses	Find and read questionnaire responses for a patient or encounter.
Flows/Update an allergy	Change the editable values of a saved allergy during an open encounter.
Flows/Register a patient	Register a new patient in Care — the fields for personal details and identifiers, and how to save the record.
Flows/View or preview a file	Open a supported file in Care or download an unsupported type.
Flows/View service requests	Find and open service requests for an encounter or facility location.
Flows/Modify the care team	Change the primary member or remove a member from an encounter's care team.
Flows/Post a message to a discussion	Read a Clinical Notes discussion and post another message.
Flows/View a diagnostic report	Open and review a diagnostic report for an encounter.
Flows/Record a diagnosis	Record one or more diagnoses during an active encounter.
Flows/Process a specimen	Record a processing step for a collected specimen.
Flows/Print a questionnaire response	Print one questionnaire response or responses to the same form.
Flows/View consents	Find and review the consents recorded for an encounter.
Flows/Update encounter details	Change the status, class, priority and hospitalization details of an open encounter.
Flows/Mark a response as entered in error	Mark an incorrect questionnaire response invalid while retaining it for audit.
Flows/Discard a specimen	Discard a specimen and record why it cannot be used.
Flows/Find discussions for a patient or an encounter	Find the separate Clinical Notes discussions for a patient or encounter.
Flows/Complete a service request	Mark a service request complete after its work is finished.
Flows/Update a consent	Change the status or note of an existing consent.
Flows/Update a diagnostic report	Change the editable details of a diagnostic report.
Flows/Rename a file	Change the display name of an uploaded file.
Flows/View a patient's profile	Open a patient's profile in Care and read the demographic, contact, and clinical information it shows in tabs.
Flows/Assign an encounter location	Record the bed or room a patient occupies during an encounter, move the patient, and correct earlier stays.
Flows/Mark an allergy as entered in error	Retract an allergy recorded by mistake while preserving the audit history.
Flows/View the care team	Open an encounter's care team and review its members, roles, and primary member.
Flows/Add a symptom or diagnosis from past records	Bring earlier symptoms or diagnoses into the current encounter.
Flows/Cancel a service request	Cancel a service request that the care team no longer needs.
Flows/Archive a file	Remove a file from active use by archiving it with a reason.
Flows/Update patient details	Edit the details of an existing patient in Care from the patient's profile — the fields you can change and how to save them.
Flows/Update a symptom or diagnosis	Change a saved symptom or diagnosis during an open encounter.
Flows/Print a diagnostic report	Open the print-formatted diagnostic report and print it.
Flows/Verify a consent	Understand consent verification data and the current product limitation.
Flows/Manage the encounter care team	Add, remove and reorder the staff who look after a patient during an encounter, and set the primary member.
Flows/View allergy history	Review a patient's allergy history across all encounters.
Flows/View specimen history	Review earlier specimens for a service request.
Flows/Manage encounter departments	Link departments to an encounter and remove them — the departments control who can see the encounter.
Flows/Download a file	Download an attached file from Care to your device.
Flows/Mark a symptom or diagnosis as entered in error	Retract a symptom or diagnosis recorded by mistake.
Flows/Manage patient identifiers	Set, view, and change a patient's identifiers in Care — required, optional, unique, format-validated, and auto-generated types.
Flows/Manage encounter tags	Apply and remove tags on an encounter, so staff can find and filter encounters later.
Flows/Manage patient tags	Add and remove tags on a patient record in Care to mark or categorize the patient, separate from clinical data.
Flows/View the clinical history	Review a patient's symptoms and diagnoses across encounters.
Flows/Discharge a patient	Record where a patient goes and when they leave the facility — the discharge does not close the encounter.
Flows/Mark a patient as deceased	Record that a patient is deceased in Care — the status and the date and time of death, from the patient's profile.
Flows/Complete an encounter	Mark an encounter as complete — the final, locked state that closes it for all further changes.
Flows/Manage patient users	Assign a user to a patient with a role in Care for field support, and remove an assigned user's access.
Flows/Restart an encounter	Reopen a completed encounter and set its status back to In Progress so the care team can record clinical data again.
Flows/View a patient's appointments and tokens	Open Patient Home in Care and view a patient's appointments and queue tokens, including the quick actions it offers.