Clinical Resources

Symptoms

Overview

The Symptoms section captures the complaints and clinical findings a patient reports or a clinician observes during an encounter.

Structuring these findings gives downstream systems a clear picture of why the patient presented and what was noted, which supports triage, documentation quality, and clinical decision-making.

Clinical Data in Source Documents

Symptoms are most often documented in the Chief Complaint, History of Present Illness, or Review of Systems sections of a clinical note.

They usually appear as short narrative phrases, for example “substernal chest pain radiating to the left arm” or “shortness of breath on exertion”, and may include qualifiers such as onset, duration, and severity.

JSON Output

During processing, the platform extracts each symptom into a structured JSON entry that records the finding and where it was documented.

Each symptom includes:

• Name: The symptom or complaint.
• Description: Supporting detail such as location, quality, or timing.
• Section Reference: The document section the symptom was found under.
• Page Number: The source page, for traceability.

{
  "symptoms": [
    {
      "name": "Chest pain",
      "description": "Substernal, radiating to the left arm, for 3 days",
      "section_header": "Chief Complaint",
      "page_number": 3
    }
  ]
}

FHIR Output

Each symptom is mapped to a FHIR Observation resource categorized as a clinical finding, which links the finding to the patient and preserves the reported detail as a note.

Key mappings include:

• Name: Populated into Observation.code.text.
• Category: Set to exam so systems can distinguish reported findings from vital signs and labs.
• Description: Captured in Observation.note.
• Patient Link: Observation.subject references the patient.

{
  "fullUrl": "urn:uuid:6b1f2c47-8d90-4a12-9e33-1c5d7a2f0b98",
  "resource": {
    "resourceType": "Observation",
    "status": "final",
    "category": [
      {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/observation-category",
            "code": "exam"
          }
        ]
      }
    ],
    "code": {
      "text": "Chest pain"
    },
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "note": [
      {
        "text": "Substernal, radiating to the left arm, for 3 days"
      }
    ]
  }
}