Clinical care

Record a symptom

This flow describes how to record a symptom for a patient during an encounter. MANSOQ stores each symptom as a condition. Pre-requisites - The patient has an open encounter at the facility, and that encounter is the patient's active encounter.…

3.1 · versioned documentation · 4 min read

Overview

This flow describes how to record a symptom for a patient during an encounter. MANSOQ stores each symptom as a condition.

Pre-requisites

• The patient has an open encounter at the facility, and that encounter is the patient's active encounter.
• The encounter is not Completed, Cancelled, Discontinued, or Entered in Error. In these states, all add and edit controls are read-only.
• You have the permissions listed below.

Note: Without an active encounter, the screen shows "Symptoms cannot be recorded without an active encounter".

Permissions

Doctors, nurses, administrators, and facility administrators have the Update Encounter related clinical data permission by default.

Without view access, the encounter shows "You do not have permission to view clinical data for this encounter".

Steps

1. Open the symptom screen

Open the encounter. Go to the Overview tab. Find the Symptoms section. Select the edit (pencil) icon.

You can also press the keyboard shortcut s on any encounter screen. The shortcut opens the same symptom screen.

The symptom screen shows the symptoms that the encounter already has.

2. Start a new symptom

Select Add Symptom. For each further symptom, the control reads Add another Symptom.

A search box opens.

3. Search for the symptom

Type a minimum of 3 characters. The screen shows a message below the search box that tells you the minimum length.

The results come from a standard SNOMED CT clinical-finding terminology.

The search box has two tabs:

• Search: the terms that match the text that you type.
• Starred: the terms that you pinned.

To pin a term, select the star icon on a result.

Note: Your administrator sets the clinical terminology for your deployment. Your administrator can also change it.

4. Select the term

Select a term. A new row appears with these default values:

If you select a term that the encounter already has, MANSOQ shows the warning "Symptom already exists!". MANSOQ does not add a second row.

5. Change the values

Change the values of the row if you need to.

Note: MANSOQ does not accept a future onset date. MANSOQ does not offer Entered in Error for a new symptom.

6. Add a note

To add a note, open the more-options (⋮) menu of the row. Select Add notes. Type the note.

Select Show notes to open the note text. Select Hide notes to close the note text.

7. Add more symptoms

Repeat from step 2 for each further symptom.

8. Submit

Select Submit.

Expected Outcome

• MANSOQ shows the confirmation "Questionnaire submitted successfully".
• The symptoms appear in the Symptoms section of the encounter Overview tab.
• The symptoms appear in the Past Symptoms clinical history of the patient.

When the encounter has no symptom, the section shows "No Symptoms" with the message "No symptoms have been recorded".

Related

Concepts:

• Condition

Flows:

• Record a diagnosis
• Add a symptom or diagnosis from past records
• Update a symptom or diagnosis
• Mark a symptom or diagnosis as entered in error
• View the clinical history

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.

• repositories/platform/mansoq-documentation/versioned_docs/version-3.1/flows/clinical/condition/record-symptom.mdx:1 · f6e9f05f