Clinical Documentation

Complaints (Symptoms)

Record what the patient reports:

Field	Description
Complaint	Select from master list or type a new one (e.g., Fever, Headache, Cough)
Duration	How long the patient has had the symptom
Severity	Mild, Moderate, Severe
Notes	Additional details about the complaint

Tip: Frequently used complaints can be pre-configured in the Complaint master for quick selection via dropdown.

Diagnosis

Record the practitioner's clinical assessment:

Field	Description
Diagnosis	Select or enter the diagnosis
Medical Code	Linked ICD-10 or SNOMED code (for standardized reporting)
Description	Additional notes about the diagnosis

Multiple diagnoses can be recorded per encounter (primary and secondary).

Vital Signs

Vital signs can be recorded directly within the encounter or via a separate Vital Signs record:

Vital	Unit
Temperature	°F or °C
Pulse / Heart Rate	bpm
Respiratory Rate	breaths/min
Blood Pressure	mmHg (systolic/diastolic)
SpO2	%
Height	cm
Weight	kg
BMI	Auto-calculated from height and weight
Nutrition Notes	Dietary observations

Clinical Notes

Free-text areas for comprehensive documentation:

• Examination details — Physical examination findings
• Clinical notes — Practitioner's observations and assessment
• Doctor Advice — Instructions given to the patient

Doctor Advice Templates can be pre-configured for frequently given advice (e.g., "Rest for 3 days", "Avoid spicy food", "Return if symptoms worsen").