diff --git a/versioned_docs/version-3.1/concepts/clinical/care-team.mdx b/versioned_docs/version-3.1/concepts/clinical/care-team.mdx index 1483118f..54642f4a 100644 --- a/versioned_docs/version-3.1/concepts/clinical/care-team.mdx +++ b/versioned_docs/version-3.1/concepts/clinical/care-team.mdx @@ -47,6 +47,6 @@ Users get these roles through their organization and facility memberships. Permi - Concept: [Encounter](../clinical/encounter.mdx) - Concept: [Patient](../clinical/patient) -- Flow: [Manage the care team of an encounter](../../flows/clinical/manage-encounter-care-team.mdx) +- Flow: [Manage the care team of an encounter](../../flows/clinical/encounter/manage-encounter-care-team.mdx) - Reference: [Care team](../../references/clinical/care-team.mdx) - Reference: [Encounter](../../references/clinical/encounter.mdx) diff --git a/versioned_docs/version-3.1/concepts/clinical/encounter.mdx b/versioned_docs/version-3.1/concepts/clinical/encounter.mdx index 442c5f5f..a6bdd556 100644 --- a/versioned_docs/version-3.1/concepts/clinical/encounter.mdx +++ b/versioned_docs/version-3.1/concepts/clinical/encounter.mdx @@ -4,74 +4,213 @@ sidebar_position: 2 # Encounter -An **encounter** is a single episode of care between a patient and a facility — an outpatient visit, an admission, an emergency presentation, or a virtual consultation. It is the working context for clinical activity: while an encounter is open, the orders, observations, medications, and notes recorded for the patient are gathered under it. +## Definition -## What it represents +An **[encounter](https://build.fhir.org/encounter.html)** in Care records one interaction between a patient and your facility. The interaction is an outpatient visit, an admission, an observation stay, an emergency visit, a virtual consultation, or a home visit. The encounter groups everything the care team records for that interaction. A patient can have more than one open encounter at the same facility at the same time. -In Care's FHIR-aligned model, an encounter maps to the **Encounter** resource. It answers four questions about one episode: what kind of interaction it is, where and when it happens, who is on the care team, and — for admissions — how the patient arrived and left. +Note: Your deployment sets the maximum number of open encounters for one patient at a facility. The default maximum is 5. -An encounter is not the patient and not the whole medical record. One patient accumulates many encounters over time; each encounter is the bounded slice of activity for a single episode, and the [patient](../clinical/patient) record is the thread that ties them together. Think of the patient as the chart and each encounter as a dated chapter within it. +Care follows the FHIR R5 Encounter resource. An encounter links to these records: -## Lifecycle +- The patient who receives the care. +- The facility and the departments that answer for the care. +- The location that the patient occupies. +- The appointment that starts the encounter. -An encounter carries a status that reflects where the episode stands. It opens as `planned` or `in_progress`, runs through active care, and ends in exactly one terminal state. Care records every transition in a status history, so the journey stays auditable. +## Key Attributes -```text -planned ──▶ in_progress ──▶ discharged ──▶ completed - ▲ │ - └───┘ on_hold (pause, then resume) -``` +| Components | What it captures | +| --- | --- | +| Status | The current state of the encounter, for example In Progress. | +| Type of Encounter | The type of care, for example Inpatient or Ambulatory. The update form calls this field Encounter Class. | +| Priority | The urgency of the care, for example Emergency or Routine. | +| Date and Time | The date and time when the encounter starts. | +| Discharge Date and Time | The date and time when the facility discharges the patient. | +| Hospital Identifier | A free-text reference number that your facility uses, such as an IP, OP, OBS or EMR number. | +| Departments | The facility departments that answer for the encounter. | +| Care team | The staff who look after the patient, each with a clinical role. | +| Current location | The bed, room or ward that the patient occupies. | +| Tags | Labels that your facility configures. | +| Hospitalization details | The admission and discharge information for a patient who stays at the facility. | +| Discharge Summary Advice | Free text that the team writes for the patient at discharge. | + +### Departments + +Each encounter needs at least one department. The departments control who can see the encounter. To change them, see [Manage Encounter departments](../../flows/clinical/encounter/manage-encounter-departments.mdx). + +### Care team -- **planned** — the episode is scheduled or expected but has not started -- **in_progress** — the patient is actively being seen or treated -- **on_hold** — care is temporarily paused (for example, awaiting results or a bed), then resumes -- **discharged** — the patient has left the facility; closing paperwork may still be in flight -- **completed** — the episode is finished and finalized +The care team lists the staff who look after the patient. Each member holds a clinical role. One member carries the primary marker. To change the team, see [Manage the Encounter care team](../../flows/clinical/encounter/manage-encounter-care-team.mdx). -An episode can also end early without reaching `completed`: **cancelled** (called off before meaningful care), **discontinued** (stopped and will not resume), or **entered_in_error** (created by mistake and voided). These, along with `completed`, are the terminal states — once an encounter reaches one, it stops accumulating new clinical activity. +### Tags -## Classification +Your facility configures the tags. Care groups them in these categories: -Two independent axes describe an encounter. **Class** answers "what kind of visit is this?" and **priority** answers "how urgent is it?". The two are set separately, so an inpatient admission can be routine and an outpatient visit can be an emergency. +- Diet +- Drug +- Lab +- Admin +- Contact +- Clinical +- Behavioral +- Research +- Advance Directive +- Safety -| Class | Meaning | +### Type of Encounter + +| Type of Encounter | Description | | --- | --- | -| `imp` | Inpatient — admitted to a bed | -| `amb` | Ambulatory — outpatient or clinic visit | -| `emer` | Emergency — emergency department presentation | -| `obsenc` | Observation — short-stay monitoring | -| `vr` | Virtual — teleconsultation | -| `hh` | Home health — care delivered at the patient's home | +| Inpatient | Patient is admitted to the hospital. | +| Ambulatory | Patient visits for outpatient care. | +| Observation | Patient is under observation. | +| Emergency | Mark as emergency if immediate attention is required. | +| Virtual | Virtual/telehealth consultation. | +| Home Health | Care provided at patient's home. | + +Note: Your deployment decides which types staff can choose. Your deployment also decides which type Care preselects. + +### Priority -Priority runs from `routine` through `urgent`, `emergency`, `ASAP`, and `stat`, with workflow values such as `elective` and `preop` for scheduled care. As with status, a change in class is recorded in its own history. +The priority states how urgent the care is. Care offers these priorities: -## How it connects +- Stat +- ASAP +- Emergency +- Urgent +- Routine +- Elective +- Rush reporting +- Timing critical +- Callback results +- Callback for scheduling +- Pre-op +- As needed +- Use as directed + +Note: Routine is the default priority on the create form. + +### Hospitalization details + +Hospitalization details appear only for the Inpatient, Observation and Emergency types. + +| Components | What it captures | +| --- | --- | +| Re-Admission | Whether the patient comes back for the same problem. | +| Admit Source | Where the patient came from. | +| Discharge Disposition | Where the patient goes after discharge. | +| Diet Preference | The dietary requirement of the patient. | + +Admit Source offers these values: + +- Transferred from other hospital +- From accident/emergency department +- From outpatient department +- Born in hospital +- General Practitioner referral +- Medical Practitioner/physician referral +- From nursing home +- From psychiatric hospital +- From rehabilitation facility +- Other + +Discharge Disposition offers these values: + +- Home +- Alternate home +- Other health care facility +- Hospice +- Long term care +- Left against advice +- Expired +- Psychiatric hospital +- Rehabilitation +- Skilled nursing facility +- Other + +Diet Preference offers these values: + +- Vegetarian +- Dairy free +- Nut free +- Gluten free +- Vegan +- Halal +- Kosher +- None + +Note: Your deployment can set a default discharge disposition. Care pre-fills that value. + +### Status + +The status shows where the encounter is in its life cycle. + +| Status | Description | +| --- | --- | +| Planned | The team plans the encounter for a future date. | +| In Progress | The team gives care to the patient now. | +| On Hold | The team pauses the encounter. | +| Discharged | The facility discharges the patient. | +| Completed | The care in this encounter ends. | +| Cancelled | The team cancels the encounter before the care starts. | +| Discontinued | The team stops the encounter before the care ends. | +| Entered in error | A user creates the encounter by mistake. | +| Unknown | The status of the encounter is not known. | -The encounter is the hub that most clinical work hangs off: +Care applies no rules about the order of the statuses. While the encounter stays open, you can move it from any status to any other status. -- **Patient** — every encounter belongs to exactly one [patient](../clinical/patient), set when it is created and never changed. -- **Facility and location** — it is anchored to a [facility](../../references/facility/facility.mdx) and tracks the [location](../../references/facility/location.mdx) the patient currently occupies within it, with a full location history behind that. -- **Booking** — an encounter can originate from a scheduling [booking](../../references/scheduling/booking.mdx), linking the appointment that brought the patient in to the episode that followed. -- **Organizations** — each encounter is associated with one or more facility [organizations](../../references/access-governance/organization.mdx), and that association is what drives who can see and act on it. -- **Clinical records** — [conditions](../clinical/condition.mdx), [observations](../clinical/observation.mdx), [service requests](../clinical/service-request.mdx), medication orders, and [notes](../clinical/notes.mdx) are all recorded in the context of an encounter. +Four statuses lock the encounter: Completed, Cancelled, Discontinued and Entered in error. After the encounter reaches one of these statuses, nobody can edit it. Nobody can record new clinical data on it. + +Discharged does not lock the encounter. A discharged encounter stays open for edits. The care team can still change the location, the care team, the departments and the tags. To close a discharged encounter, someone must mark it as complete. See [Complete an Encounter](../../flows/clinical/encounter/complete-encounter.mdx). + +Note: Your deployment sets how long after its last change someone can restart a completed encounter. The default is zero hours, which stops all restarts. + +## Where to find Encounters + +The facility sidebar holds a Patients group. The group contains Search Patients, one list for each allowed encounter type, and Locations. The group also contains All Encounters when your deployment allows more than one encounter type. + +Note: Your deployment sets the default date filter on the encounter lists. + +The encounter page holds these tabs: Overview, Plots, Observations, Medicines, Responses, Service Requests, Diagnostic Reports, Files, Notes, Devices and Consents. Every tab except Overview, Devices and Consents needs permission to read clinical data. + +The encounter page also holds an **Encounter Actions** command palette. Press `Shift+E` to open it. + +The Overview tab carries a side panel with these actions: + +- Manage Consents +- Manage Care Team +- Update Location +- Update Department +- Dispense + +The Overview tab also carries a button. The button reads **Mark for discharge** or **Mark as Completed**. + +A left rail lets you move between the encounters of the patient. The rail filters the encounters by status, department, care team, date and tags. ## Permissions -Access to encounters is permission-controlled, and every action on the encounter endpoint is reserved for clinical roles. Listing and retrieving an encounter is also granted when the user can view the underlying patient. +Your role controls what you can do with an encounter. Administrators, Doctors, Nurses and Facility Administrators hold these permissions. -| Permission | Description | System Roles | -| --- | --- | --- | -| `can_create_encounter` | Open a new encounter for a patient under a facility | Admin, Doctor, Nurse, Facility Admin | -| `can_list_encounter` | List encounters within a facility (clinical data is not exposed through this permission) | Admin, Doctor, Nurse, Facility Admin | -| `can_read_encounter` | Retrieve an encounter's non-clinical details | Admin, Doctor, Nurse, Facility Admin | -| `can_write_encounter` | Update an encounter, manage its organizations, set facility identifiers, assign care-team members, and restart a completed encounter | Admin, Doctor, Nurse, Facility Admin | +| Permission | What it allows | +| --- | --- | +| Can Create encounter | Create an encounter. | +| Can Read encounter | Open an encounter. | +| Can list encounters | See the encounter lists. | +| Update Encounter non clinical | Change the details of the encounter. Manage its departments, care team, location, tags, completion and restart. | +| Can Read encounter related clinical data | Open the clinical tabs. | +| Update Encounter related clinical data | Record clinical data. | +| Can submit questionnaire about patient encounters | Answer questionnaires about the encounter. Staff also hold this permission. | -Roles are granted to users through their organization, facility, and patient memberships, and permissions cascade down the organization tree — a role held at a parent organization applies to the facilities and encounters beneath it. +You can also reach an encounter through the department that owns the current bed of the patient. The departments of the encounter are not the only route. ## Related -- Reference: [Encounter (technical)](../../references/clinical/encounter.mdx) -- Concept: [Patient](../clinical/patient) -- Concept: [Condition](../clinical/condition.mdx) -- Concept: [Service request](../clinical/service-request.mdx) -- Concept: [Notes](../clinical/notes.mdx) +- Flow: [Create an Encounter](../../flows/clinical/encounter/create-encounter.mdx) +- Flow: [Update Encounter details](../../flows/clinical/encounter/update-encounter-details.mdx) +- Flow: [Assign an Encounter location](../../flows/clinical/encounter/assign-encounter-location.mdx) +- Flow: [Manage the Encounter care team](../../flows/clinical/encounter/manage-encounter-care-team.mdx) +- Flow: [Manage Encounter departments](../../flows/clinical/encounter/manage-encounter-departments.mdx) +- Flow: [Manage Encounter tags](../../flows/clinical/encounter/manage-encounter-tags.mdx) +- Flow: [Discharge a patient](../../flows/clinical/encounter/discharge-patient.mdx) +- Flow: [Complete an Encounter](../../flows/clinical/encounter/complete-encounter.mdx) +- Flow: [Restart an Encounter](../../flows/clinical/encounter/restart-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/_category_.json b/versioned_docs/version-3.1/flows/clinical/encounter/_category_.json new file mode 100644 index 00000000..96810d47 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/_category_.json @@ -0,0 +1,5 @@ +{ + "label": "Encounter", + "position": 2, + "key": "clinical-encounter-flows" +} diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/assign-encounter-location.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/assign-encounter-location.mdx new file mode 100644 index 00000000..2083f94d --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/assign-encounter-location.mdx @@ -0,0 +1,104 @@ +--- +sidebar_position: 3 +--- + +# Assign an encounter location + +## Overview + +This flow describes how to record the bed or room that a patient occupies during an [encounter](../../../concepts/clinical/encounter.mdx). It also describes how to move the patient to another location and how to correct earlier stays. + +## Pre-requisites + +- The patient has an open encounter at your facility, and you opened that encounter. +- The facility has locations set up in Care. +- The bed or room that you want belongs to the same facility as the encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Lets you assign, move, correct, close and cancel the locations of an encounter. Administrator, Doctor, Nurse and Facility Administrator hold this permission. | + +You also need permission to see the locations of the facility. + +## Steps + +### 1. Open the location sheet + +Go to the encounter page. Then use one of these entry points: + +- Open **Encounter Actions** with the shortcut `Shift+E`. Select **Assign Location**. +- Press `l` on the encounter page. +- On the **Overview** tab side panel, select **Update Location**. + +The location sheet opens. The sheet has two tabs: **Assign** and **History**. + +### 2. Assign a location + +1. Open the **Assign** tab. +2. Browse the locations of the facility. +3. Select the bed or room that the patient occupies. You can select only a real place, such as a bed or a room. You cannot select a location category. +4. Set the state of the stay. A stay is planned, reserved or active. Only one stay stays active at a time. +5. Set the start time. +6. If the stay has an end time, set the end time. +7. Confirm. + +Note: Care groups locations in these forms: + +- Site, Building, Wing, Ward, Level and Corridor +- Room, Bed, Cabinet and House +- Vehicle, Road, Area and Jurisdiction +- Virtual + +### 3. Move the patient to another location + +1. Select the new bed or room. +2. Choose the move action. +3. Care asks whether to keep the previous bed reserved for the patient, or to free it. Choose one option. +4. Confirm. + +### 4. Handle an occupied bed + +- If another patient occupies the bed in an open encounter, Care blocks the assignment. Care tells you that the bed is occupied. You cannot override this. Free that bed first. +- If the patient who occupies the bed is discharged, Care asks you to confirm. Confirm to move the new patient in. + +### 5. Correct an earlier stay + +1. Open the **History** tab. The tab lists the earlier stays of the patient for this encounter. +2. Select the stay that you want to change. +3. Correct the times of the stay, close the stay, or cancel the stay. +4. Care asks you to confirm before it removes a stay. Confirm. + +### 6. Rules that Care applies + +- The end time must be the same as or later than the start time. If it is earlier, Care shows "End Datetime should be greater than Start Datetime". +- A closed stay needs an end time. If the end time is missing, Care shows "End Datetime is required for completed status". +- After you close a stay, you cannot change the state of that stay again. +- Two stays cannot overlap at the same location. If they overlap, Care shows "Conflict in schedule". +- The location and the encounter must belong to the same facility. + +## Expected Outcome + +- The encounter shows the current bed or room of the patient. +- While the patient occupies a bed, Care shows the bed as reserved. When the stay closes, Care shows the bed as available again. +- The **History** tab lists each stay of the patient for this encounter. +- When you set the encounter status to Completed, Cancelled, Discontinued or Entered in error, Care closes any open stay for you. +- A discharged encounter still holds its location. Care frees the bed only when the stay closes, or when someone marks the encounter as complete. + +Note: A user who belongs to the department that owns the current bed of the patient can open the encounter. This applies even when that user does not belong to the departments of the encounter. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Update Encounter details](./update-encounter-details.mdx) +- [Manage Encounter departments](./manage-encounter-departments.mdx) +- [Discharge a patient](./discharge-patient.mdx) +- [Complete an Encounter](./complete-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/complete-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/complete-encounter.mdx new file mode 100644 index 00000000..5538306b --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/complete-encounter.mdx @@ -0,0 +1,62 @@ +--- +sidebar_position: 8 +--- + +# Complete an encounter + +## Overview + +This flow describes how to mark an [encounter](../../../concepts/clinical/encounter.mdx) as complete in Care. A completed encounter is closed for all further changes. + +## Pre-requisites + +- The care team recorded everything for this interaction. +- If the facility admits the patient, discharge the patient first. See [Discharge a patient](./discharge-patient.mdx). +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Lets you mark the encounter as complete. Administrator, Doctor, Nurse and Facility Administrator have this permission. | + +## Steps + +### 1. Open the action + +Open the encounter. Use one of these entry points: + +- On the **Overview** tab side panel, select the bottom button **Mark as Completed**. +- Open **Encounter Actions** with the shortcut `Shift+E`. Then select **Mark as Completed**. The keyboard shortcut for this action is `m` then `c`. + +Note: If the encounter is Inpatient and you did not discharge the patient yet, Care does not show the confirmation dialog. Care opens the encounter form with the discharge already selected. Complete the discharge first. + +### 2. Confirm the action + +Care shows the dialog **Mark as Complete**. The dialog asks "Are you sure you would like to mark this encounter as complete?". + +Select **Mark as Complete** to confirm. Press `Enter` to confirm. Select **Cancel** or press `Escape` to close the dialog. + +## Expected Outcome + +- Care shows "Encounter Completed". +- Care sets the status to **Completed** and records the end of the encounter. +- If the encounter came from an appointment, Care closes the appointment and its token as fulfilled. Care shows "Appointment closed successfully". +- Care closes any open location stay and frees the bed. +- Care releases any device linked to the encounter. + +After the encounter closes, nobody can change it. Nobody can record new clinical data on it. The encounter stays available to read. To open the encounter again, see [Restart an Encounter](./restart-encounter.mdx). + +Note: The same lock applies to the statuses Cancelled, Discontinued and Entered in error. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Discharge a patient](./discharge-patient.mdx) +- [Restart an Encounter](./restart-encounter.mdx) +- [Update Encounter details](./update-encounter-details.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/create-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/create-encounter.mdx new file mode 100644 index 00000000..db5ff7f6 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/create-encounter.mdx @@ -0,0 +1,104 @@ +--- +sidebar_position: 1 +--- + +# Create an encounter + +## Overview + +This flow describes how to create an [encounter](../../../concepts/clinical/encounter.mdx) for a patient at a facility. You can start the encounter from the patient page or from an appointment. + +## Pre-requisites + +- The patient is registered in Care, and you have opened the patient at the facility. +- If you start the encounter from an appointment, the patient has a booked or checked-in appointment at that facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Create encounter | Lets you create an encounter for a patient at the facility. Administrator, Doctor, Nurse and Facility Administrator have this permission. | + +Note: If you do not have this permission, Care does not show the action. + +## Steps + +### 1. Open the encounter form + +You can open the form from four places. + +**From the patient page.** Open the patient at the facility. Select the **Create Encounter** quick action. Keyboard shortcut: `e`. + +**From the patient's Encounters tab.** Open the patient. Go to the **Encounters** tab. Select **Create Encounter**. This action appears when the patient has no encounter yet. + +**From an appointment, with Start Consultation.** Open the appointment page. In **Quick Actions**, select **Start Consultation**. Keyboard shortcut: `1`. Care opens the form with the status set to **In Progress**. Care also links the encounter to the appointment. When you confirm, Care moves the appointment to In Consultation. + +Note: If the appointment already has an encounter, **Start Consultation** does not open the form. Care moves the appointment to In Consultation. Care then opens the existing encounter on its Overview tab. + +**From an appointment, with Create Planned Encounter.** In the same **Quick Actions** panel, select **Create Planned Encounter**. Keyboard shortcut: `2`. Care opens the form with the status set to **Planned**. + +The form is titled **Initiate Patient Encounter**. Below the title, Care shows "Begin a new clinical encounter for" and the name of the patient. + +### 2. Complete the form + +Complete the fields in the order they appear. + +| Component | What it captures | +| --- | --- | +| Date and Time (required) | The date and the time the encounter starts. You can pick a future date only when the status is Planned. | +| Type of Encounter (required) | The kind of care the patient receives. Select one tile. See the tile list below. | +| Status (required) | The state of the encounter. Choose In Progress, Planned or On Hold. These are the only statuses you can set at creation. | +| Priority (required) | How urgent the encounter is. Care preselects Routine. For the full list, see [Encounter](../../../concepts/clinical/encounter.mdx). | +| Tags (optional) | One or more tags that your facility configured for encounters. | +| Departments (required) | The departments that look after the patient. Select at least one department. Departments control who can see the encounter. | + +Each **Type of Encounter** tile carries a short description. + +| Type of Encounter | Description | +| --- | --- | +| Inpatient | Patient is admitted to the hospital. | +| Ambulatory | Patient visits for outpatient care. | +| Observation | Patient is under observation. | +| Emergency | Mark as emergency if immediate attention is required. | +| Virtual | Virtual/telehealth consultation. | +| Home Health | Care provided at patient's home. | + +Note: Which encounter types you can choose, and which type Care preselects, depend on your deployment's configuration. + +### 3. Save the encounter + +Select **Create Encounter**. The button shows "Creating…" while Care saves the encounter. To close the form without saving, select **Cancel**. + +If Care shows an error, correct the entry and save again. + +| Message | What to do | +| --- | --- | +| Future date is only allowed for planned encounters | The start date is in the future, but the status is not Planned. Move the date back, or set the status to Planned. | +| At least one department is required | Select a department. The **Create Encounter** button stays disabled until you select one. | +| Patient already has maximum number of active encounters (5) in the facility | The patient already has the maximum number of open encounters at this facility. Close one of them, or continue in the existing encounter. | +| Encounter already has an associated booking | The appointment you started from already has an encounter. Open that encounter instead. | + +Note: The maximum number of open encounters per patient at a facility depends on your deployment's configuration. The default maximum is 5. + +## Expected Outcome + +- Care shows the message "Encounter created successfully". +- Care opens the new encounter on its Overview tab. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Update Encounter details](./update-encounter-details.mdx) +- [Assign an Encounter location](./assign-encounter-location.mdx) +- [Manage the Encounter care team](./manage-encounter-care-team.mdx) +- [Manage Encounter departments](./manage-encounter-departments.mdx) +- [Manage Encounter tags](./manage-encounter-tags.mdx) +- [Discharge a patient](./discharge-patient.mdx) +- [Complete an Encounter](./complete-encounter.mdx) +- [Restart an Encounter](./restart-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/discharge-patient.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/discharge-patient.mdx new file mode 100644 index 00000000..32a7da0b --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/discharge-patient.mdx @@ -0,0 +1,131 @@ +--- +sidebar_position: 7 +--- + +# Discharge a patient + +## Overview + +This flow describes how to discharge a patient from an [encounter](../../../concepts/clinical/encounter.mdx) in Care. The discharge records where the patient goes, and when the patient leaves the facility. + +Note: The discharge does not close the encounter. The encounter stays open until someone marks it as complete. + +## Pre-requisites + +- The patient has an open encounter of the type Inpatient, Observation or Emergency. +- The patient is ready to leave the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Lets you record the discharge on an encounter. Administrator, Doctor, Nurse and Facility Administrator hold this permission. | + +## Steps + +### 1. Start the discharge + +Open the encounter. Start the discharge from one of these entry points: + +- On the **Overview** tab side panel, select the bottom button **Mark for discharge**. +- Open **Encounter Actions**, then select **Mark for discharge**. The shortcut for **Encounter Actions** is `Shift+E`. The shortcut for the discharge is `m` then `c`. +- Open the encounter form, then select **Discharge Patient**. The shortcut for the encounter form is `Shift+U`. + +Care sets the **Encounter Status** to **Discharged**. Care disables this field. + +Note: For an Inpatient encounter that is not discharged yet, Care does not show the completion dialog. Care opens the encounter form with the discharge already selected. You then fill in the discharge details. + +### 2. Select the Discharge Disposition + +Select where the patient goes. This field is required. + +| Component | What it captures | +| --- | --- | +| Discharge Disposition | The place the patient goes to after the facility. | + +The choices are: + +- Home +- Alternate home +- Other health care facility +- Hospice +- Long term care +- Left against advice +- Expired +- Psychiatric hospital +- Rehabilitation +- Skilled nursing facility +- Other + +Care marks this field with an asterisk. Care refuses the form until you fill it in, for Inpatient, Observation and Emergency encounters. + +Note: Your deployment can pre-fill a default discharge disposition. + +### 3. Set the Discharge Date and Time + +Set when the patient leaves the facility. Care shows this field after the status becomes **Discharged**. The time cannot be earlier than the start of the encounter. + +### 4. Write the Discharge Summary Advice + +Write the advice the patient takes home. This field is optional. + +### 5. Check the Hospitalization Details + +Check the rest of the **Hospitalization Details**: + +| Component | What it captures | +| --- | --- | +| Admit Source | Where the patient came from. | +| Re-Admission | A switch. Turn it on when the patient comes back for the same problem. | +| Diet Preference | The dietary requirement of the patient. | + +**Admit Source** offers these choices: + +- Transferred from other hospital +- From accident/emergency department +- From outpatient department +- Born in hospital +- General Practitioner referral +- Medical Practitioner/physician referral +- From nursing home +- From psychiatric hospital +- From rehabilitation facility +- Other + +**Diet Preference** offers these choices: + +- Vegetarian +- Dairy free +- Nut free +- Gluten free +- Vegan +- Halal +- Kosher +- None + +### 6. Submit the form + +Submit the form to save the discharge. + +## Expected Outcome + +- Care marks the encounter as **Discharged**. +- The encounter stays open. The care team can still change the encounter, the location, the care team, the departments and the tags. +- The patient keeps the bed until someone closes the location stay. Care frees the bed when the stay closes, or when someone marks the encounter as complete. See [Assign an Encounter location](./assign-encounter-location.mdx). +- To close the encounter, someone must mark it as complete. See [Complete an Encounter](./complete-encounter.mdx). +- Care can move a discharged encounter to another status. Care applies no rules about which status follows which. + +Note: Your deployment decides which encounter types your facility uses. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Update Encounter details](./update-encounter-details.mdx) +- [Assign an Encounter location](./assign-encounter-location.mdx) +- [Complete an Encounter](./complete-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-care-team.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-care-team.mdx new file mode 100644 index 00000000..591be9fe --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-care-team.mdx @@ -0,0 +1,77 @@ +--- +sidebar_position: 4 +--- + +# Manage the encounter care team + +## Overview + +This flow describes how to manage the care team of an [encounter](../../../concepts/clinical/encounter.mdx) in Care. The care team lists the staff who look after the patient, and the role of each person. + +## Pre-requisites + +- The patient has an open encounter at your facility, and you opened that encounter. +- The staff you want to add are members of a department at the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Lets you add, remove, and reorder the members of the care team. Administrator, Doctor, Nurse and Facility Administrator have this permission. | + +Note: If you can open the encounter but you cannot change it, Care shows the same list in read-only form. + +## Steps + +### 1. Open the care team sheet + +Open the encounter page. Then use one of these entry points: + +- Select **Encounter Actions** (shortcut `Shift+E`). Then select **Manage Care Team**. +- Or, on the **Overview** tab side panel, select **Manage Care Team**. + +Care opens a sheet titled **Manage Care Team**. If you can only read the team, the sheet is titled **View Care Team**. + +Note: Care defines no keyboard shortcut for **Manage Care Team**. + +### 2. Add a member + +1. Select the department the person belongs to. +2. Open **Select Member** and choose the person. Care lists only the users of the department you chose. +3. Open **Select Role** and choose the clinical role of the person. Care shows the roles that match your search. +4. Select **Add**. Care shows "Member added successfully". + +Note: The list of roles comes from a clinical terminology set. Your deployment can offer a different set of roles from another deployment. + +If you select a person who is already on the team, Care shows "Member already added". + +### 3. Set the primary member + +Select **Mark as Primary** on a member. Care moves that person to the top of the list. Care shows "Primary member updated". Care asks for no confirmation. + +Note: Care keeps the first person in the list as the primary member. Care marks that person **Primary**. + +### 4. Remove a member + +Select **Remove** on the member. Care opens the **Confirm Removing Member** dialog. Select **Remove** again. Care shows "Member removed successfully". + +## Expected Outcome + +- The care team of the encounter shows the staff you added, with the role of each person. +- The primary member is at the top of the list. +- Care saves the whole team together each time you change it. + +Note: Membership of the care team can give a user access to the encounter. Add only the staff who look after the patient. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Assign an Encounter location](./assign-encounter-location.mdx) +- [Manage Encounter departments](./manage-encounter-departments.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-departments.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-departments.mdx new file mode 100644 index 00000000..f3ddb61f --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-departments.mdx @@ -0,0 +1,75 @@ +--- +sidebar_position: 5 +--- + +# Manage encounter departments + +## Overview + +This flow describes how to link departments to an [encounter](../../../concepts/clinical/encounter.mdx), and how to remove them. + +Departments decide who can see the encounter. Staff of a linked department can open the encounter. Every encounter has at least one department. You choose the first department when you create the encounter. + +## Pre-requisites + +- The patient has an open encounter at your facility, and you opened that encounter. +- The departments you want belong to the same facility as the encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Link a department to the encounter, and remove a linked department. Administrator, Doctor, Nurse and Facility Administrator have this permission. | + +## Steps + +### 1. Open the department sheet + +Go to the encounter page. + +Use one of these entry points: + +- Open **Encounter Actions** with the `Shift+E` shortcut, then select **Update Department**. +- On the **Overview** tab side panel, select **Update Department**. + +Note: Care defines no keyboard shortcut for the **Update Department** action. + +### 2. Add a department + +1. Open the department selector. +2. Select one or more departments. + +Care links each department to the encounter as you select it. + +The department must belong to the facility of the encounter. If it does not, Care shows "Organization Incompatible with Encounter". + +You cannot link the same department twice. If you try, Care shows "Organization already exists". + +### 3. Remove a department + +1. Find the department in the list of linked departments. +2. Select the delete icon beside the department. + +Care shows "Organization removed successfully". + +You cannot remove a department that is not linked. If you try, Care shows "Organization does not exist". + +## Expected Outcome + +- The encounter shows the linked departments in the list of departments. +- Staff of each linked department can open the encounter. + +Note: A user of the department that owns the current bed of the patient can also open the encounter. This applies even when Care does not link that department to the encounter. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Assign an Encounter location](./assign-encounter-location.mdx) +- [Manage the Encounter care team](./manage-encounter-care-team.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-tags.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-tags.mdx new file mode 100644 index 00000000..0d85f87e --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/manage-encounter-tags.mdx @@ -0,0 +1,76 @@ +--- +sidebar_position: 6 +--- + +# Manage encounter tags + +## Overview + +This flow describes how to apply and remove tags on an [encounter](../../../concepts/clinical/encounter.mdx) in Care. A tag is a label your facility configures to mark an encounter. Staff use tags to find and filter encounters later. + +An administrator groups tags into these categories: + +- Diet +- Drug +- Lab +- Admin +- Contact +- Clinical +- Behavioral +- Research +- Advance Directive +- Safety + +## Pre-requisites + +- The patient has an open encounter at your facility, and you opened that encounter. +- An administrator has set up tags for encounters at your facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Apply and remove tags on an encounter. Administrator, Doctor, Nurse and Facility Administrator have this permission. | + +Note: You also need permission for each tag you apply. An administrator can restrict a tag. + +## Steps + +### 1. Open the Encounter Tags panel + +Go to the encounter page. Select the **Overview** tab. Find the **Encounter Tags** panel. + +Note: Care shows the edit icon only when you can change the encounter. + +Note: Care does not list this action in the Encounter Actions palette. You can also set tags when you create the encounter. + +### 2. Apply the tags + +Select the edit icon on the **Encounter Tags** panel. In the sheet, select the tags to apply. Care shows only the tags that your facility configured for encounters. + +Care applies these rules: + +- A tag must be set up for encounters. If it is not, Care shows "Tag resource does not match resource type". +- You cannot apply the same tag twice. Care shows "Tag already set". +- Some tags belong to a group in which only one tag can apply at a time. If one of these tags is already on the encounter, Care shows "Tag Parent is already set". Remove the other tag first. + +### 3. Remove a tag + +To take a tag off the encounter, remove it from the same sheet. + +## Expected Outcome + +- Care shows the applied tags in the **Encounter Tags** panel. +- You can filter the patient's encounters by tag in the encounter selector on the encounter page. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Update Encounter details](./update-encounter-details.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/restart-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/restart-encounter.mdx new file mode 100644 index 00000000..6837b699 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/restart-encounter.mdx @@ -0,0 +1,60 @@ +--- +sidebar_position: 9 +--- + +# Restart an encounter + +## Overview + +This flow describes how to reopen a completed [encounter](../../../concepts/clinical/encounter.mdx) in Care. Care sets the status back to In Progress, and the care team can record clinical data again. + +## Pre-requisites + +- The encounter status is Completed. +- You work within the facility that owns the encounter. +- Someone marked the encounter as complete by mistake, or the care team must record more for the same interaction. +- You open the encounter itself. Care hides the action when you look at another encounter of the same patient in the side selector. +- Your deployment allows restarts. Read the note in the Steps section before you start. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Restart a completed encounter. Administrator, Doctor, Nurse and Facility Administrator hold this permission. | + +## Steps + +### 1. Open the encounter actions + +On the encounter page, open **Encounter Actions**. You can also press `Shift+E`. + +Note: Care shows **Restart Encounter** only when the encounter status is Completed. Care also needs you to work within the facility that owns the encounter. + +### 2. Select Restart Encounter + +Select **Restart Encounter**. Care defines no keyboard shortcut for this action. + +Care acts at once. It asks for no confirmation. + +Note: Your deployment sets how many hours after the last change you can restart a completed encounter. The default is zero hours. With that setting, Care refuses every restart. When the limit stops you, Care shows "Encounter cannot be restarted after 0 hours" with the number that your deployment set. Ask your administrator to raise the limit if your facility needs restarts. + +## Expected Outcome + +- Care shows "Encounter restarted successfully". +- Care opens the encounter on its **Overview** tab. +- Care sets the encounter status to **In Progress**. +- The care team can record clinical data again. +- If the restart fails, Care shows "Failed to restart encounter". + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Update Encounter details](./update-encounter-details.mdx) +- [Complete an Encounter](./complete-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/encounter/update-encounter-details.mdx b/versioned_docs/version-3.1/flows/clinical/encounter/update-encounter-details.mdx new file mode 100644 index 00000000..7aaf29e9 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/encounter/update-encounter-details.mdx @@ -0,0 +1,103 @@ +--- +sidebar_position: 2 +--- + +# Update encounter details + +## Overview + +This flow describes how to change the details of an open [encounter](../../../concepts/clinical/encounter.mdx) in Care. You can change the status, the class, the priority and the hospitalization details. + +## Pre-requisites + +- The patient has an open encounter at your facility, and you opened that encounter. +- If the encounter is Completed, Cancelled, Discontinued or Entered in error, Care refuses every change. You cannot use this flow. +- If the patient is discharged, the encounter is still open. You can still update it. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Lets you change the non-clinical details of an encounter. Administrators, Doctors, Nurses and Facility Administrators hold this permission. | + +## Steps + +### 1. Open the encounter form + +Go to the encounter page. + +Open **Encounter Actions**. The keyboard shortcut is `Shift+E`. + +Select **Update Encounter Details**. + +Note: You can also press `Shift+U` on the encounter page. This shortcut opens the same form directly. + +### 2. Set the encounter status, class and priority + +Care shows the encounter form. Complete these required fields. + +| Component | What it captures | +| --- | --- | +| Encounter Status | The current state of the encounter. Choose Planned, In Progress, On Hold, Completed, Cancelled, Discontinued or Entered in error. | +| Encounter Class | The type of care. Choose Inpatient, Ambulatory, Observation, Emergency, Virtual or Home Health. | +| Priority | The urgency of the encounter. For the full list, see [Encounter](../../../concepts/clinical/encounter.mdx). | + +Note: The create form calls the **Encounter Class** field **Type of Encounter**. Both fields hold the same value. + +Note: The status list does not hold Discharged. You set that status with the discharge button. See [Discharge a patient](./discharge-patient.mdx). + +Note: After the patient is discharged, Care disables the **Encounter Status** field. + +Note: Which encounter classes you can choose depends on your deployment's configuration. + +Note: Care applies no rules about the order of statuses. While the encounter is open, you can set any status in the list. + +### 3. Enter the hospital identifier + +Enter the facility's reference number for this encounter in **Hospital Identifier**. The field shows the hint "IP/OP/OBS/EMR Number". + +This field is optional. + +### 4. Enter the discharge summary advice + +Care shows **Discharge Summary Advice** after the patient is discharged. Care also shows it when the encounter already holds advice. + +Enter the advice for the patient in the text box. This field is optional. + +If you clear the text and save the form, Care removes the earlier advice. + +### 5. Complete the hospitalization details + +Care shows the **Hospitalization Details** section only for Inpatient, Observation and Emergency encounters. + +| Component | What it captures | +| --- | --- | +| Re-Admission | A switch. Turn it on when the patient comes back for the same problem. | +| Admit Source | Where the patient came from. | +| Discharge Disposition | Where the patient goes after discharge. | +| Diet Preference | The dietary requirement of the patient. | + +For the full list of choices in each field, see [Encounter](../../../concepts/clinical/encounter.mdx). + +### 6. Submit the form + +Submit the form. Care saves the encounter. + +## Expected Outcome + +- Care saves the new encounter details. +- Care keeps a history of every status change and every encounter class change on the encounter. +- If you set the status to Completed, Cancelled, Discontinued or Entered in error, Care closes any open location stay for the encounter. Care also releases any device linked to the encounter. After that, nobody can edit the encounter. + +## Related + +Concepts: + +- [Encounter](../../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an Encounter](./create-encounter.mdx) +- [Discharge a patient](./discharge-patient.mdx) +- [Complete an Encounter](./complete-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/manage-encounter-care-team.mdx b/versioned_docs/version-3.1/flows/clinical/manage-encounter-care-team.mdx deleted file mode 100644 index a8655579..00000000 --- a/versioned_docs/version-3.1/flows/clinical/manage-encounter-care-team.mdx +++ /dev/null @@ -1,77 +0,0 @@ ---- -sidebar_position: 2 ---- - -# How to manage the care team of an encounter - -## Overview - -This flow describes how to add, remove, and order the members of the [care team](../../concepts/clinical/care-team.mdx) of an [encounter](../../concepts/clinical/encounter.mdx). - -## Pre-requisites - -- The patient is registered in Care. -- The encounter is open at your facility. You cannot change the care team of a completed encounter. -- Each user that you add is a member of a department in the same facility. -- Each user that you add can see the encounter. -- You have the permissions listed below. - -## Permissions - -| Permission | Access | -| --- | --- | -| Can Read encounter | See the care team of the encounter. | -| Update Encounter non clinical | Add a member, remove a member, or change the primary member. | - -Without the update permission, Care shows the care team as read-only. The title of the panel is then **View Care Team**. - -## Steps - -### 1. Open the encounter - -Go to the facility, and select the patient encounter that you want to change. The encounter opens on the **Updates** tab. - -### 2. Open the care team panel - -Find the **Manage Care Team** panel in the summary panel of the encounter. Select the edit icon. Care opens the care team sheet. - -You can also open the sheet from the command dialog. Press `Shift + E` to open the command dialog, then select **Manage Care Team**. - -### 3. Select the department - -Select a facility department in the organization selector at the top of the sheet. Care then shows the users of that department. - -### 4. Add a member - -| Components | What it captures | -| --- | --- | -| Member | The user that you add to the care team. Use **Select Member**. | -| Role | The practitioner role of the member. Use **Select Role**. | - -Select **Add**. Care adds the member and shows the message "Member added successfully". - -:::note -A user can be in the care team only one time. If the user is already a member, Care shows the message "Member already added". -::: - -### 5. Set the primary member - -Care marks the first member in the list with the **Primary** badge. To make a different member primary, select **Mark as Primary** on that member. Care moves the member to the top of the list. - -### 6. Remove a member - -Select the remove action on the member, then confirm the action. Care shows the message "Member removed successfully". - -## Expected Outcome - -- The care team of the encounter holds the members that you selected, each with a practitioner role. -- The primary member is at the top of the list, and Care shows that member on the encounter card. -- The encounter is now in the encounter list of each member of the care team. - -## Related - -Concepts: - -- [Care team](../../concepts/clinical/care-team.mdx) -- [Encounter](../../concepts/clinical/encounter.mdx) -- [Patient](../../concepts/clinical/patient) diff --git a/versioned_docs/version-3.1/references/clinical/care-team.mdx b/versioned_docs/version-3.1/references/clinical/care-team.mdx index 82cb87b9..3a8434a0 100644 --- a/versioned_docs/version-3.1/references/clinical/care-team.mdx +++ b/versioned_docs/version-3.1/references/clinical/care-team.mdx @@ -81,4 +81,4 @@ On read, each member is expanded from the cached `UserSpec` for the stored `user - Concept: [Care team](../../concepts/clinical/care-team.mdx) - Reference: [Encounter](../clinical/encounter.mdx) - Reference: [User](../access-governance/user.mdx) -- Flow: [How to manage the care team of an encounter](../../flows/clinical/manage-encounter-care-team.mdx) +- Flow: [How to manage the care team of an encounter](../../flows/clinical/encounter/manage-encounter-care-team.mdx) diff --git a/versioned_sidebars/version-3.1-sidebars.json b/versioned_sidebars/version-3.1-sidebars.json index 5f6c5e33..2fbf494b 100644 --- a/versioned_sidebars/version-3.1-sidebars.json +++ b/versioned_sidebars/version-3.1-sidebars.json @@ -38,7 +38,22 @@ "flows/clinical/patient/view-patient-appointments" ] }, - "flows/clinical/manage-encounter-care-team" + { + "type": "category", + "label": "Encounter", + "key": "clinical-encounter-flows", + "items": [ + "flows/clinical/encounter/create-encounter", + "flows/clinical/encounter/update-encounter-details", + "flows/clinical/encounter/assign-encounter-location", + "flows/clinical/encounter/manage-encounter-care-team", + "flows/clinical/encounter/manage-encounter-departments", + "flows/clinical/encounter/manage-encounter-tags", + "flows/clinical/encounter/discharge-patient", + "flows/clinical/encounter/complete-encounter", + "flows/clinical/encounter/restart-encounter" + ] + } ] }, {