> ## Documentation Index
> Fetch the complete documentation index at: https://userguide.tesacloud.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Patient Observations

> Recording medical observations and notes for patients

# Patient Observations

Record important medical observations, history, and pre-operative notes for each patient.

## What Are Observations?

Observations capture clinical information about the patient's condition:

* **Chief Complaint** - Primary reason for surgery
* **Injury/Onset Date** - When the condition began
* **Medical History** - Relevant past conditions
* **Pre-Operative Assessment** - Clinical findings before surgery

## Adding an Observation

<Steps>
  <Step title="Open Patient Profile">
    Navigate to the patient's profile
  </Step>

  <Step title="Click Add Observation">
    Click the observation icon or **Add Observation** button
  </Step>

  <Step title="Enter Details">
    Complete the observation form:

    * Select observation type
    * Enter date of observation
    * Add clinical notes
  </Step>

  <Step title="Save">
    Click **Save** to record the observation
  </Step>
</Steps>

## Observation Types

| Type                 | Description                         |
| -------------------- | ----------------------------------- |
| Chief Complaint      | Primary symptom or reason for visit |
| Injury Date          | Date of injury or symptom onset     |
| Medical History      | Relevant past medical conditions    |
| Physical Examination | Clinical examination findings       |
| Imaging Results      | X-ray, MRI, CT findings             |
| Pre-Op Notes         | Pre-operative assessment notes      |

## Voice-to-Text

Use voice input to quickly record observations:

<Steps>
  <Step title="Click Microphone Icon">
    Click the microphone button in the text field
  </Step>

  <Step title="Speak Your Notes">
    Dictate your observation clearly
  </Step>

  <Step title="Review Transcription">
    Check the transcribed text for accuracy
  </Step>

  <Step title="Edit if Needed">
    Make any necessary corrections
  </Step>
</Steps>

<Tip>
  Voice-to-text supports multiple languages and medical terminology. Speak clearly and at a moderate pace for best results.
</Tip>

## Editing Observations

To modify an existing observation:

<Steps>
  <Step title="Open Patient Profile">
    Navigate to the patient's observations
  </Step>

  <Step title="Select Observation">
    Click on the observation you want to edit
  </Step>

  <Step title="Make Changes">
    Update the information as needed
  </Step>

  <Step title="Save Changes">
    Click **Save** to confirm
  </Step>
</Steps>

## Best Practices

* Record observations as soon as possible for accuracy
* Use consistent terminology
* Include relevant dates and measurements
* Reference imaging studies by date and type