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overview

The Condition module allows healthcare providers to record a patient’s illness or medical issue at the time of their visit. It includes all relevant clinical information—such as symptoms, lab tests, radiology, and physical exam findings. This section forms the foundation for initiating follow-ups, treatments, and tracking the progress of the condition over time.

When to Use

Use the Condition module whenever a patient presents with a medical issue, symptom, or diagnosis during a clinic visit. This includes both new and existing conditions that require documentation, evaluation, treatment, or follow-up. Conditions should also be used to record chronic illnesses, acute complaints, post-operative states, and any case that involves clinical assessment or intervention.

Information Captured in a Condition

  • Basic information:(condition name,location…)
  • Chief complaint:(ICD10 code)
  • Present history
  • Physical exam:
  • Differential diagnoses:(ICD10 code)
  • Diagnoses:(ICD10 code)
  • Medications
  • Attachments or related files