Outpatient visits

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This section describes the management of outpatient visits within 4Geeks Health. Outpatient visits are appointments where patients receive medical services without being admitted to the hospital for an overnight stay.

Understanding Outpatient Visits¶

In 4Geeks Health, an outpatient visit represents a single encounter between a patient and a healthcare provider for a specific medical service. It encompasses the entire process, from scheduling the appointment to completing the consultation and any follow-up actions. Outpatient visits are often linked to appointments but can also be created independently.

Accessing Outpatient Visits¶

You can typically access Outpatient Visits in the following ways:

1. From the Navigation Menu:

   • Look for an “Outpatient,” “Visits,” or “Encounters” option in the main navigation menu.
   • Click this option.

2. From the Appointments Page:

   • After scheduling an appointment, there might be an option to directly create an associated outpatient visit.
   • You might be able to convert an existing appointment into an outpatient visit.

3. From a Patient Record:

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

Creating an Outpatient Visit¶

There are a couple of primary ways to create an outpatient visit:

1. From an Appointment¶

This is the most common and recommended method, as it links the visit to the scheduled appointment.

• Schedule an Appointment: Follow the steps outlined in the “Appointments” documentation to schedule an appointment for the patient.
• Start Consultation: Click the scheduled appointment, and you should see a “Start Consultation” button, you should click the button.
• Automatic Visit Creation: The visit will be automatically filled with the appointment information.

2. Manually Creating an Outpatient Visit¶

Use this method if the visit is not directly tied to a pre-scheduled appointment (e.g., a walk-in patient).

• Access the Outpatient Visits Page: Navigate to the Outpatient Visits section as described above.
• Create New Visit: Click a “New Outpatient Visit,” “Create Visit,” “Add Encounter,” or similar button.
• Fill in the Details: You’ll need to manually enter the following information:
  • Patient *: Select the patient from the patient list (start typing their name or ID). Mandatory.
  • Practitioner *: Select the healthcare provider for the visit. Mandatory.
  • Date *: The date of the visit. Mandatory.
  • Time: The time of the visit (or the start time).
  • Visit Type/Reason: (Optional) Select a visit type (e.g., Consultation, Follow-up, Vaccination).
  • Department: (Optional) If your organization uses departments, select the relevant department.
  • Notes: Any initial notes about the visit.

The Outpatient Visit Record¶

The Outpatient Visit record serves as a central hub for all information related to the patient’s encounter. It typically includes the following sections:

• Visit Details: Basic information like patient, practitioner, date, time, and visit type.
• Vitals: A section to record vital signs (e.g., temperature, blood pressure, heart rate, weight, height). See the separate “Vital Signs” documentation for details.
• Medical History: Access and update the patient’s medical history.
• Progress Notes/SOAP Notes: The core of the clinical documentation. The practitioner records their observations, assessments, and plans. Often follows the SOAP (Subjective, Objective, Assessment, Plan) format.
• Orders:
  • Medication Orders: Prescribe medications for the patient. This may link to a pharmacy module.
  • Lab Orders: Order laboratory tests for the patient. This may link to a laboratory information system (LIS).
  • Procedure Orders: Order other procedures (e.g., imaging, referrals).
• Billing: Information related to billing and charges for the visit. This may integrate with the accounting module.
• Attachments: Attach relevant documents (e.g., scanned reports, images).

Completing an Outpatient Visit¶

The process of completing an outpatient visit typically involves:

1. Recording Vitals: Take and record the patient’s vital signs.
2. Taking History: Discuss with the Patient the medical history.
3. Documenting the Encounter: The practitioner completes the progress notes (SOAP notes) detailing their findings, diagnosis, and treatment plan.
4. Creating Orders: Prescribe medications, order lab tests, or order other procedures as needed.
5. Scheduling Follow-up: If necessary, schedule a follow-up appointment.
6. Marking as Complete: There may be a button or status to mark the visit as “Completed” or “Closed.” This often triggers billing processes.
7. Generating Documents: Print documents related to the appointment.

Editing and Managing Outpatient Visits¶

• Find the Visit: Navigate to the Outpatient Visits list and find the visit you want to manage.
• Open the Visit: Click on the visit to open its record.
• Edit: Look for an “Edit” button to modify visit details, notes, or orders. Note that some information may be locked after the visit is completed.
• Add Information: You can usually continue adding information to the visit record even after the initial encounter (e.g., adding lab results when they become available).

Important Considerations¶

• Workflow: Understand your organization’s specific workflow for outpatient visits. There may be variations in the order of steps or required fields.
• User Permissions: Different user roles may have different levels of access to create, edit, and complete outpatient visits.
• Integration: Outpatient visits are often tightly integrated with other modules, such as Appointments, Patient Records, Laboratory, Pharmacy, and Billing.
• Compliance: Ensure that all documentation and processes comply with relevant regulations (e.g., HIPAA, GDPR).

This documentation provides a comprehensive guide to managing outpatient visits in 4Geeks Health. Remember to adapt any specific field names, button labels, or steps to match your organization’s customized configuration.