List patient's signs and symptoms

A symptom is a subjective indication of a disease or a change in condition, as perceived by the patient. A sign is an objective finding, usually detected on physical examination, from a test, or on an x-ray, that indicates the presence of abnormality or disease.

  1. At the top of the page, click the Narrative tab.

    The contents of the Narrative tab appear, set to the Impressions bookmark in the left pane.

  2. In the left pane, click the Signs/Symptoms bookmark.

    The right pane scrolls down to the top of the Supporting Signs/Symptoms section of the page.

  3. Click Add Sign/Symptom.

    The Add Sign/Symptom dialog box appears.

  4. For Category, click the field or the list icon to the right of the field, then select the appropriate single option from the menu that appears, to choose a general collection of observed signs or symptoms expressed by the patient.

    Example: Abdomen and digestive symptoms

    The Sign/Symptom field activates.

  5. ForSign/Symptom, click the field or the list icon to the right of the field, then select the appropriate single option from the menu that appears, to choose a specific sign or symptom.

    Example: Abdomiman distension (gaseous) or constipation

  6. Click OK.

    The sign or symptom you added appears as a listing in the Supporting Signs/Symptoms section.

  7. Repeat the previous steps to list all the signs and symptoms observed by fEMS personnel or expressed by the patient. .