Condition
Definition
A condition in Care is a clinical problem that affects a patient. Care records a condition as a symptom or as a diagnosis. A symptom is what the patient reports or the clinician observes. A diagnosis is the clinician's determination of the condition.
Every symptom and every diagnosis belongs to one patient. You record it against one encounter. You do not select the patient separately, because Care uses the patient of the encounter.
Key Attributes
Symptoms and diagnoses capture the same attributes.
| Components | What it captures |
|---|---|
| Clinical Term | The clinical term for the condition. You select it from a standard SNOMED CT clinical-finding terminology. There is no default, so you must select one. |
| Status | The current clinical state of the condition. The default is Active. |
| Verification | How certain the record is. The default is Confirmed. |
| Severity | How severe the condition is. The default is Moderate. For a diagnosis you can leave it empty, and the field then shows "Choose severity". |
| Onset Date | When the condition started. The default is today. Care does not accept a future date. |
| Note | Free text about the condition. The default is empty. |
Status
The Status shows the current clinical state of the condition. Select one of these values:
- Active
- Recurrence
- Relapse
- Inactive
- Remission
- Resolved
Verification
The Verification shows how certain the record is. Select one of these values:
- Unconfirmed
- Provisional
- Differential
- Confirmed
- Refuted
- Entered in Error
Severity
The Severity shows how severe the condition is. Select one of these values:
- Mild
- Moderate
- Severe
Category
A diagnosis also shows a category badge with the label Diagnosis. This badge marks the record as specific to that visit.
Terminology
The clinical terms come from a standard SNOMED CT clinical-finding terminology. The same terminology serves symptoms and diagnoses.
Note: Your deployment's administrator can change the available terminology.
Lifecycle
You record symptoms and diagnoses from the Overview tab of the encounter. Use the Symptoms section and the Diagnoses section.
You cannot record a symptom or a diagnosis without an active encounter. Without an active encounter, the screen shows "Symptoms cannot be recorded without an active encounter" or "Diagnosis cannot be recorded without an active encounter".
While the encounter is open, you can change the Status, the Verification, the Severity, and the Note of a saved record. You cannot change the Onset Date after you save the record.
Care never deletes a saved symptom or diagnosis. To retract one, set its Verification to Entered in Error. The record stays visible with that label. Care leaves the records with the Verification value Entered in Error out of the Past Symptoms list and the Past Diagnoses list.
Symptoms and diagnoses stay with the patient. The clinical history of the patient shows them across all encounters. Use the Past Symptoms tab and the Past Diagnoses tab.
Permissions
Your role controls what you can do with a symptom or a diagnosis.
| Permission | What it allows |
|---|---|
| Can view clinical data about patients | View the symptoms and the diagnoses of a patient. |
| Can Read encounter related clinical data | View the symptoms and the diagnoses of an encounter. |
| Update Encounter related clinical data | Record and change symptoms and diagnoses. |
By default, doctors, nurses, administrators, and facility administrators can record and change clinical data. Staff can view patient clinical data, but staff do not have encounter clinical-data access.
All add and edit controls are read-only when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.
FHIR R5 alignment
Care follows FHIR R5 for conditions. The clinical term, the status, the verification, the severity, the category, the onset date, and the note map to the FHIR Condition resource.