Flows/Update a symptom or diagnosis

flowclinicalCARE 3.1+

Clinical

Concepts

Patient

Encounter Care team Condition Allergy & Intolerance Observation Diagnostic Report Service Request Specimen Consent Clinical Notes

Questionnaire Response

Flows

Search for a patient

Register a patient View a patient's profile Update patient details Manage patient identifiers Manage patient tags Mark a patient as deceased Manage patient users View a patient's appointments and tokens Create an encounter Update encounter details Assign an encounter location Manage the encounter care team Manage encounter departments Manage encounter tags Discharge a patient Complete an encounter

Restart an encounter

References

Patient

Encounter Care team Condition Allergy Intolerance Observation Diagnostic Report Consent Notes Specimen Service Request

Questionnaire Response

Overview

This flow describes how to change a symptom or a diagnosis that you already recorded. Care stores each of them as a condition. Use this flow when the patient improves, or when a provisional finding becomes confirmed.

Pre-requisites

• You or a colleague recorded the symptom or the diagnosis on the encounter.
• The encounter is the patient's active encounter.
• The encounter status is not Completed, Cancelled, Discontinued, or Entered in Error. In these states you can only read the record.
• You have the permissions listed below.

Permissions

Permission	Access
Can view clinical data about patients	View the symptoms and the diagnoses of the patient
Can Read encounter related clinical data	View the symptoms and the diagnoses of the encounter
Update Encounter related clinical data	Change a recorded symptom or diagnosis

Steps

1. Open the symptom screen or the diagnosis screen

Go to the Overview tab of the encounter.

For a symptom, select the edit (pencil) icon in the Symptoms section. You can also press the keyboard shortcut s.

For a diagnosis, select the edit (pencil) icon in the Diagnoses section. You can also press the keyboard shortcut d.

The records of the encounter show in a list. Each record shows in its own row.

2. Change the values

Change the values that you need. You can change these fields on a saved record:

Component	What it captures
Status	Active, Recurrence, Relapse, Inactive, Remission, or Resolved.
Verification	Unconfirmed, Provisional, Differential, Confirmed, or Refuted.
Severity	Mild, Moderate, or Severe.
Note	Free text about the record.

📝 Note

The Verification value Entered in Error shows only if the record already has that value. To retract a record, see Mark a symptom or diagnosis as entered in error.

📝 Note

For a diagnosis you can leave the Severity field empty. The field then shows "Choose severity".

To add a note, open the more-options (⋮) menu of the row. Select Add notes. Select Show notes to open the note text. Select Hide notes to close the note text.

3. Know the fields that you cannot change

You cannot change the Onset Date of a saved record. The field is unavailable after the first submission.

You cannot change the clinical term of a saved record. To correct a wrong term, mark the record as entered in error. Then record the correct term.

4. Submit the changes

Select Submit.

Expected Outcome

• Care shows the confirmation "Questionnaire submitted successfully".
• The updated values show in the Symptoms section or the Diagnoses section of the encounter Overview tab.
• The updated values show in the clinical history of the patient.

Clinical

Concepts

Patient · Encounter · Care team · Condition · Allergy · Observation · Dx Report · Service Request · Specimen · Consent · Notes · Q. Response

Flows

Search · Register · Profile · Update · Identifiers · Tags · Deceased · Users · Appointments · Create Encounter · Update Encounter · Location · Care Team · Departments · Tags · Discharge · Complete · Restart

References

Patient · Encounter · Care team · Condition · Allergy · Observation · Dx Report · Consent · Notes · Specimen · Service Request · Q. Response

Related

• Concept: Concepts/Condition

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