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Consultations

This section describes how to document and manage patient consultations within 4Geeks Health. Consultations are a core component of patient care, representing the interaction between a healthcare provider and a patient to discuss their health concerns, perform examinations, make diagnoses, and develop treatment plans.

What is a Consultation?

In 4Geeks Health, a Consultation record represents a specific instance of a healthcare provider meeting with a patient to provide medical advice, assessment, and/or treatment. Consultations are typically linked to:

  • Appointments: A consultation often occurs as part of a scheduled appointment.
  • Outpatient Visits: For outpatients, the consultation is the main component of the visit.
  • Inpatient Encounters: For inpatients, consultations may occur throughout their hospital stay.

Accessing Consultations

You can access Consultations in several ways:

  1. From the Navigation Menu:

    • Look for a “Consultations,” “Encounters,” “Visits,” or similar option in the main navigation menu.
    • Click this option.

  2. From an Appointment:

    • When you start an appointment (mark it as “In Progress”), a corresponding consultation record may be automatically created.
    • There may be a button or link within the appointment view to access the associated consultation.

  3. From a Patient Record:

    • While viewing a patient’s record, there may be a section for “Consultations,” “Encounters,” or “Visits.”
    • You might find a button to create a new consultation for that patient.

  4. From Outpatient Visit/Inpatient Record:

    • When starting a consultation from the Appointment list the Outpatient Visit form will be displayed.

Creating a Consultation Record

The method for creating a consultation record depends on how you access it:

  • Schedule an appointment for the patient (see the “Appointments” documentation).
  • When the patient arrives and the consultation is about to begin, open the appointment.
  • Click a “Start Consultation,” “Begin Visit,” or similar button. This action usually:
    • Changes the appointment status to “In Progress.”
    • Automatically creates a linked consultation record.
    • Prefills the consultation record with information from the appointment (patient, provider, date, time).

2. Manually Creating a Consultation

  • Navigate to the Consultations section using one of the access methods described above.
  • Click a “New Consultation,” “Add Encounter,” or similar button.
  • Manually enter the following information:
    • Patient *: Select the patient from the patient list. Mandatory.
    • Practitioner *: Select the healthcare provider conducting the consultation. Mandatory.
    • Date and Time *: The date and time of the consultation. Mandatory.
    • Consultation Type: (Optional) Select a type (e.g., Initial Consultation, Follow-up, Specialist Consultation).
    • Department: (Optional) If applicable, select the relevant department.
    • Referring Provider: (Optional) If the patient was referred by another provider, record that information here.

The Consultation Record

The Consultation record is the central location for documenting all aspects of the patient encounter. It typically includes the following sections:

  • Basic Information: Patient, provider, date, time, consultation type.
  • Chief Complaint: The patient’s primary reason for seeking medical attention.
  • History of Present Illness (HPI): A detailed description of the patient’s current symptoms and their history.
  • Past Medical History (PMH): A summary of the patient’s past medical conditions, surgeries, allergies, and medications. This information may be pulled from the patient’s overall medical record.
  • Social History: Information about the patient’s lifestyle, habits, and social environment (e.g., smoking, alcohol use, occupation).
  • Family History: Information about medical conditions in the patient’s family.
  • Review of Systems (ROS): A systematic inquiry about symptoms in different body systems (e.g., cardiovascular, respiratory, gastrointestinal).
  • Physical Examination: Documentation of the provider’s physical examination findings. This may be organized by body system.
  • Vital Signs: Record the patient’s vital signs (temperature, blood pressure, heart rate, respiratory rate, weight, height). See the separate “Vital Signs” documentation.
  • Assessment: The provider’s diagnosis or differential diagnosis (list of possible diagnoses).
  • Plan: The provider’s plan for managing the patient’s condition. This may include:
    • Medication Orders: Prescribing medications.
    • Lab Orders: Ordering laboratory tests.
    • Procedure Orders: Ordering other procedures (e.g., imaging, referrals).
    • Therapy Orders: Ordering therapies (e.g., physical therapy, occupational therapy).
    • Education/Counseling: Information and advice provided to the patient.
    • Follow-up: Instructions for follow-up appointments.
  • Notes: Additional notes or comments.
  • Attachments: Attach relevant documents (e.g., scanned reports, images).

SOAP Notes

Many healthcare providers use the SOAP (Subjective, Objective, Assessment, Plan) format to structure their consultation notes. The Consultation record in 4Geeks Health may have dedicated fields or sections for each component of SOAP:

  • Subjective (S): Information provided by the patient (chief complaint, HPI, history).
  • Objective (O): Observable and measurable findings (physical exam, vital signs, lab results).
  • Assessment (A): The provider’s diagnosis or differential diagnosis.
  • Plan (P): The treatment plan.

Completing a Consultation

  1. Document Thoroughly: Ensure all relevant information is documented in the appropriate sections of the consultation record.
  2. Create Orders: Create any necessary orders (medications, labs, procedures, therapy).
  3. Schedule Follow-up: If needed, schedule a follow-up appointment.
  4. Mark as Complete: There may be a button or status to mark the consultation as “Completed,” “Closed,” or similar. This often triggers billing processes.

Managing Consultation Records

  • View: Find and open existing consultation records from the Consultations list or from the patient’s record.
  • Edit: You may be able to edit certain fields in the consultation record (e.g., to add notes or correct errors). However, some fields (like the date and time) may be locked after the record is created.
  • Print: You may be able to print a summary of the consultation record.

Important Considerations

  • Documentation Standards: Follow your organization’s documentation standards for consultations. This may include specific templates, required fields, or the use of SOAP notes.
  • User Permissions: Different user roles may have different levels of access to create, edit, and view consultation records.
  • Integration: Consultations are tightly integrated with other modules, such as Appointments, Patient Records, Laboratory, Pharmacy, and Billing.
  • Confidentiality: Maintain strict patient confidentiality and adhere to all relevant privacy regulations (e.g., HIPAA).
  • Training: Provide proper training for all staff that will be creating the consultations.

This documentation provides a comprehensive overview of managing consultations in 4Geeks Health. Remember to adapt any specific field names, button labels, or steps to match your organization’s customized configuration and specific workflows.