diff --git a/versioned_docs/version-3.0/concepts/clinical/encounter.mdx b/versioned_docs/version-3.0/concepts/clinical/encounter.mdx index 442c5f5f..2f181b8c 100644 --- a/versioned_docs/version-3.0/concepts/clinical/encounter.mdx +++ b/versioned_docs/version-3.0/concepts/clinical/encounter.mdx @@ -4,74 +4,104 @@ 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 is one episode of care +between a patient and a facility. An outpatient visit, an admission, an emergency +presentation, and a teleconsultation are each an encounter. Care groups the clinical +records of that episode under the encounter. -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. +One patient has many encounters over time. The +[patient](../clinical/patient) record is the thread that joins them. -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. +## Key Attributes -## Lifecycle - -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. +| Components | What it captures | +| --- | --- | +| Date and Time | The time the episode starts. | +| Type of Encounter | The kind of episode: Ambulatory, Emergency, Inpatient, Observation, Home Health, or Virtual. | +| Status | The stage the episode is at. | +| Priority | The urgency of the episode, for example Routine, Urgent, or Emergency. | +| Departments | The facility departments that the encounter belongs to. Care uses these departments to control access. | +| Tags | The labels that staff attach to the encounter. | +| Location | The location that the patient occupies in the facility, with the full location history. | +| Care Team | The users who care for the patient in this episode, each with a role. | +| Hospital Identifier | The identifier that the facility gives the episode, for example an inpatient number. | +| Hospitalization Details | The admission and discharge details of an inpatient, observation, or emergency episode. | +| Discharge Summary Advice | The advice that a clinician records for the patient at discharge. | + +### Type of Encounter + +| Type | Description | +| --- | --- | +| Ambulatory | The patient visits for outpatient care. | +| Emergency | The patient needs immediate attention. | +| Inpatient | The facility admits the patient to a bed. | +| Observation | The facility keeps the patient under observation. | +| Home Health | Staff give care at the home of the patient. | +| Virtual | The clinician sees the patient in a teleconsultation. | -```text -planned ──▶ in_progress ──▶ discharged ──▶ completed - ▲ │ - └───┘ on_hold (pause, then resume) -``` +Note: Your deployment configures which types of encounter Care shows, and which type +Care selects first. -- **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 +### Hospitalization Details -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. +Care shows these details only for an Inpatient, Observation, or Emergency encounter: -## Classification +- **Re-admission** — the patient returns for the same problem. +- **Admit Source** — where the patient comes from, for example From outpatient + department or Transferred from other hospital. +- **Discharge Disposition** — where the patient goes at discharge, for example Home or + Other health care facility. +- **Discharge Date and Time** — the time the episode ends. +- **Diet Preference** — the diet the patient needs, for example Vegetarian or Halal. -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. +### Status -| Class | Meaning | +| Status | 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 | - -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. - -## How it connects - -The encounter is the hub that most clinical work hangs off: - -- **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. +| Planned | Staff expect the episode, but the episode has not started. | +| In Progress | A clinician sees or treats the patient now. | +| On Hold | Care pauses, for example to wait for a bed, and resumes later. | +| Discharged | The patient leaves the facility. Staff can still complete the paperwork. | +| Completed | The episode is finished. | +| Cancelled | Staff call the episode off before care starts. | +| Discontinued | Staff stop the episode, and the episode does not resume. | +| Entered in error | Staff create the encounter by mistake. | +| Unknown | The stage of the episode is not known. | + +Completed, Cancelled, Discontinued, and Entered in error are closed statuses. A closed +encounter accepts no new clinical records. A user with a role that can update an +encounter can restart a Completed encounter within the time limit that your deployment +sets. + +Care keeps a history of every status change and every type change. ## 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. +Care grants roles to a user through the facility departments that the user belongs to. +Permissions cascade down the department tree. A role that a user holds at a parent +department applies to the departments below it. | 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 | +| Can Create encounter | Start an encounter for a patient at a facility | Admin, Doctor, Nurse, Facility Admin | +| Can list encounters | List the encounters of a facility. This permission gives no access to clinical data. | Admin, Doctor, Nurse, Facility Admin | +| Can Read encounter | Open one encounter and read the details that are not clinical | Admin, Doctor, Nurse, Facility Admin | +| Can Read encounter related clinical data | Read the clinical records of the encounter | Admin, Doctor, Nurse, Facility Admin | +| Update Encounter non clinical | Update the encounter, manage its departments and identifiers, set the care team, and restart a closed encounter | Admin, Doctor, Nurse, Facility Admin | +| Update Encounter related clinical data | Update the clinical records of the encounter | Admin, Doctor, Nurse, Facility Admin | +| Can submit questionnaire about patient encounters | Submit a questionnaire against the encounter | Admin, Doctor, Nurse, Staff, Facility Admin | -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. +A user who can view the patient can also list and open the encounters of that patient. ## Related -- Reference: [Encounter (technical)](../../references/clinical/encounter.mdx) +- Flow: [Create an encounter](../../flows/clinical/create-an-encounter.mdx) +- Flow: [Assign a location to an encounter](../../flows/clinical/assign-a-location-to-an-encounter.mdx) +- Flow: [Close an encounter](../../flows/clinical/close-an-encounter.mdx) - Concept: [Patient](../clinical/patient) - Concept: [Condition](../clinical/condition.mdx) - Concept: [Service request](../clinical/service-request.mdx) - Concept: [Notes](../clinical/notes.mdx) +- Reference: [Encounter](../../references/clinical/encounter.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/assign-a-location-to-an-encounter.mdx b/versioned_docs/version-3.0/flows/clinical/assign-a-location-to-an-encounter.mdx new file mode 100644 index 00000000..90483083 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/assign-a-location-to-an-encounter.mdx @@ -0,0 +1,80 @@ +--- +sidebar_position: 3 +--- + +# How to assign a location to an encounter + +## Overview + +This flow describes how to record the location that a patient occupies during an +[encounter](../../concepts/clinical/encounter.mdx). Care keeps the current location and +the full location history of the encounter. + +## Pre-requisites + +- The encounter is open. If there is no encounter, + [create an encounter](./create-an-encounter.mdx) first. +- The encounter is not closed. Care blocks updates to a closed encounter. +- An administrator has set up the locations and beds of your facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Read encounter | Open the encounter | +| Update Encounter non clinical | Assign, move, or end the location of the patient | + +## Steps + +### 1. Open the encounter + +From the facility dashboard, select **Encounters**. Select the encounter. + +### 2. Open the location panel + +Select **Assign Location**. The **Update Location** panel opens. + +:::note +The keyboard shortcut **l** opens **Assign Location**. The shortcut **shift+e** opens +the command dialog, which lists every encounter action. +::: + +### 3. Select a location + +Select the **Assign Location** tab. Select the location, then select the bed. + +To find a bed, enter the name of the bed in the search box. To hide the beds that are in +use, turn on the available filter. + +### 4. Confirm the bed + +Select the bed to assign it now, or schedule the bed for a later time. + +If the current patient of the bed leaves soon, Care shows **Confirm Selection**. Select +**Proceed** to take the bed. + +If the bed is in use and the free time is not known, Care shows **Bed Occupied**. Select +**Close**, then select a different bed. + +### 5. Check the history + +Select the **Location History** tab. The tab lists every location of the encounter, with +the newest first. + +## Expected Outcome + +- The encounter shows the new location of the patient. +- Care adds the location to the location history of the encounter. +- Staff who have access to that location can now see the encounter. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/close-an-encounter.mdx b/versioned_docs/version-3.0/flows/clinical/close-an-encounter.mdx new file mode 100644 index 00000000..75b842a7 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/close-an-encounter.mdx @@ -0,0 +1,107 @@ +--- +sidebar_position: 4 +--- + +# How to close an encounter + +## Overview + +This flow describes how to end an +[encounter](../../concepts/clinical/encounter.mdx) when care for the episode is +finished. A closed encounter accepts no new clinical records. + +## Pre-requisites + +- The encounter is open, and the encounter is not closed already. +- Staff record the clinical data of the episode. Care blocks new records after you close + the encounter. +- If the patient occupies a bed, staff end the location stay. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Read encounter | Open the encounter | +| Update Encounter non clinical | Change the status of the encounter and record the discharge details | + +## Steps + +### 1. Open the encounter + +From the facility dashboard, select **Encounters**. Select the encounter. + +### 2. Open the encounter details + +Select **Update Encounter Details**. The encounter form opens. + +:::note +The keyboard shortcut **shift+u** opens **Update Encounter Details**. +::: + +### 3. Discharge the patient + +In the **Discharge Patient** panel, select **Mark for discharge**. Care sets the status +to Discharged. + +Note: After the status is Discharged, you cannot change the status in this form. + +### 4. Record the discharge details + +For an Inpatient, Observation, or Emergency encounter, complete the **Hospitalization +Details** section: + +| Components | What it captures | +| --- | --- | +| Re-admission | Whether the patient returns for the same problem. | +| Admit Source | Where the patient comes from, for example From outpatient department. | +| Discharge Disposition | Where the patient goes, for example Home or Other health care facility. | +| Discharge Date and Time | The time the episode ends. | +| Diet Preference | The diet that the patient needs. | + +Enter the advice for the patient in **Discharge Summary Advice**. + +Note: Your deployment can set the discharge disposition that Care selects first. + +### 5. Complete the encounter + +Select **Mark as Completed** in the encounter actions. Care shows the **Mark as +Complete** dialog. + +If the encounter still needs a discharge, the action shows as **Mark for discharge**. + +Read the message in the dialog. Care can also close the appointment and the token of the +patient. + +Select **Mark as Complete** to confirm. To keep the encounter open, select **Cancel**. + +:::note +The keyboard shortcut **m c** opens the **Mark as Completed** action. +::: + +### 6. Open the discharge summary + +Open the **Reports** panel of the encounter. Select the discharge summary template of +your facility. Care shows the report for the encounter. + +## Expected Outcome + +- The encounter status is Completed. +- Care blocks new clinical records against the encounter. +- The discharge summary advice shows in the summary of the encounter. + +:::note +To reopen a Completed encounter, select **Restart Encounter** in the encounter actions. +Care allows a restart only within the time limit that your deployment sets. +::: + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/create-an-encounter.mdx b/versioned_docs/version-3.0/flows/clinical/create-an-encounter.mdx new file mode 100644 index 00000000..9a162746 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/create-an-encounter.mdx @@ -0,0 +1,95 @@ +--- +sidebar_position: 2 +--- + +# How to create an encounter + +## Overview + +This flow describes how to start an +[encounter](../../concepts/clinical/encounter.mdx) for a patient at your facility. The +encounter is the episode of care that holds the clinical records of the visit. + +## Pre-requisites + +- The patient is registered in Care. If the patient is new, first + [register the patient](../../concepts/clinical/patient). +- You belong to a department of the facility that treats the patient. +- If you start the encounter from an appointment, the patient has a booked or checked-in + appointment at the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Create encounter | Start an encounter for a patient at the facility | +| Can Read encounter | Open the encounter after Care creates it | + +## Steps + +### 1. Open the patient + +From the facility dashboard, select **Patients**. Select the patient. + +### 2. Start the encounter + +Select **Create Encounter**. The **Initiate Patient Encounter** panel opens. + +You can also start the encounter from the **Encounters** tab of the patient. + +To start an encounter from an appointment, open the appointment. Select **Start +Consultation** to begin care now. Select **Create Planned Encounter** to record an +episode that starts later. + +:::note +On the patient page, the keyboard shortcut **e** opens **Create Encounter**. On the +appointment page, **1** starts a consultation and **2** creates an encounter. +::: + +### 3. Enter the encounter details + +Complete the panel: + +| Components | What it captures | +| --- | --- | +| Date and Time | The time the episode starts. Care fills in the current time. | +| Type of Encounter | The kind of episode: Ambulatory, Emergency, Inpatient, Observation, Home Health, or Virtual. | +| Status | Planned, In Progress, or On Hold. | +| Priority | The urgency of the episode, for example Routine, Urgent, or Emergency. | +| Tags | The labels that your facility uses for encounters. | +| Departments | The facility departments that the encounter belongs to. | + +Note: Which types of encounter you can select depends on the configuration of your +deployment. + +A future date is only allowed for a planned encounter. + +### 4. Select a department + +Select at least one department. Care keeps **Create Encounter** disabled until you +select a department. + +Care uses the department to decide who can see and update the encounter. + +### 5. Save the encounter + +Select **Create Encounter**. To cancel the panel, select **Cancel**. + +## Expected Outcome + +- Care shows the message "Encounter created successfully". +- Care opens the **Updates** tab of the new encounter. +- The encounter shows in the **Encounters** tab of the patient. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Close an encounter](./close-an-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..2f181b8c 100644 --- a/versioned_docs/version-3.1/concepts/clinical/encounter.mdx +++ b/versioned_docs/version-3.1/concepts/clinical/encounter.mdx @@ -4,74 +4,104 @@ 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 is one episode of care +between a patient and a facility. An outpatient visit, an admission, an emergency +presentation, and a teleconsultation are each an encounter. Care groups the clinical +records of that episode under the encounter. -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. +One patient has many encounters over time. The +[patient](../clinical/patient) record is the thread that joins them. -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. +## Key Attributes -## Lifecycle - -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. +| Components | What it captures | +| --- | --- | +| Date and Time | The time the episode starts. | +| Type of Encounter | The kind of episode: Ambulatory, Emergency, Inpatient, Observation, Home Health, or Virtual. | +| Status | The stage the episode is at. | +| Priority | The urgency of the episode, for example Routine, Urgent, or Emergency. | +| Departments | The facility departments that the encounter belongs to. Care uses these departments to control access. | +| Tags | The labels that staff attach to the encounter. | +| Location | The location that the patient occupies in the facility, with the full location history. | +| Care Team | The users who care for the patient in this episode, each with a role. | +| Hospital Identifier | The identifier that the facility gives the episode, for example an inpatient number. | +| Hospitalization Details | The admission and discharge details of an inpatient, observation, or emergency episode. | +| Discharge Summary Advice | The advice that a clinician records for the patient at discharge. | + +### Type of Encounter + +| Type | Description | +| --- | --- | +| Ambulatory | The patient visits for outpatient care. | +| Emergency | The patient needs immediate attention. | +| Inpatient | The facility admits the patient to a bed. | +| Observation | The facility keeps the patient under observation. | +| Home Health | Staff give care at the home of the patient. | +| Virtual | The clinician sees the patient in a teleconsultation. | -```text -planned ──▶ in_progress ──▶ discharged ──▶ completed - ▲ │ - └───┘ on_hold (pause, then resume) -``` +Note: Your deployment configures which types of encounter Care shows, and which type +Care selects first. -- **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 +### Hospitalization Details -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. +Care shows these details only for an Inpatient, Observation, or Emergency encounter: -## Classification +- **Re-admission** — the patient returns for the same problem. +- **Admit Source** — where the patient comes from, for example From outpatient + department or Transferred from other hospital. +- **Discharge Disposition** — where the patient goes at discharge, for example Home or + Other health care facility. +- **Discharge Date and Time** — the time the episode ends. +- **Diet Preference** — the diet the patient needs, for example Vegetarian or Halal. -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. +### Status -| Class | Meaning | +| Status | 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 | - -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. - -## How it connects - -The encounter is the hub that most clinical work hangs off: - -- **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. +| Planned | Staff expect the episode, but the episode has not started. | +| In Progress | A clinician sees or treats the patient now. | +| On Hold | Care pauses, for example to wait for a bed, and resumes later. | +| Discharged | The patient leaves the facility. Staff can still complete the paperwork. | +| Completed | The episode is finished. | +| Cancelled | Staff call the episode off before care starts. | +| Discontinued | Staff stop the episode, and the episode does not resume. | +| Entered in error | Staff create the encounter by mistake. | +| Unknown | The stage of the episode is not known. | + +Completed, Cancelled, Discontinued, and Entered in error are closed statuses. A closed +encounter accepts no new clinical records. A user with a role that can update an +encounter can restart a Completed encounter within the time limit that your deployment +sets. + +Care keeps a history of every status change and every type change. ## 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. +Care grants roles to a user through the facility departments that the user belongs to. +Permissions cascade down the department tree. A role that a user holds at a parent +department applies to the departments below it. | 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 | +| Can Create encounter | Start an encounter for a patient at a facility | Admin, Doctor, Nurse, Facility Admin | +| Can list encounters | List the encounters of a facility. This permission gives no access to clinical data. | Admin, Doctor, Nurse, Facility Admin | +| Can Read encounter | Open one encounter and read the details that are not clinical | Admin, Doctor, Nurse, Facility Admin | +| Can Read encounter related clinical data | Read the clinical records of the encounter | Admin, Doctor, Nurse, Facility Admin | +| Update Encounter non clinical | Update the encounter, manage its departments and identifiers, set the care team, and restart a closed encounter | Admin, Doctor, Nurse, Facility Admin | +| Update Encounter related clinical data | Update the clinical records of the encounter | Admin, Doctor, Nurse, Facility Admin | +| Can submit questionnaire about patient encounters | Submit a questionnaire against the encounter | Admin, Doctor, Nurse, Staff, Facility Admin | -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. +A user who can view the patient can also list and open the encounters of that patient. ## Related -- Reference: [Encounter (technical)](../../references/clinical/encounter.mdx) +- Flow: [Create an encounter](../../flows/clinical/create-an-encounter.mdx) +- Flow: [Assign a location to an encounter](../../flows/clinical/assign-a-location-to-an-encounter.mdx) +- Flow: [Close an encounter](../../flows/clinical/close-an-encounter.mdx) - Concept: [Patient](../clinical/patient) - Concept: [Condition](../clinical/condition.mdx) - Concept: [Service request](../clinical/service-request.mdx) - Concept: [Notes](../clinical/notes.mdx) +- Reference: [Encounter](../../references/clinical/encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/assign-a-location-to-an-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/assign-a-location-to-an-encounter.mdx new file mode 100644 index 00000000..90483083 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/assign-a-location-to-an-encounter.mdx @@ -0,0 +1,80 @@ +--- +sidebar_position: 3 +--- + +# How to assign a location to an encounter + +## Overview + +This flow describes how to record the location that a patient occupies during an +[encounter](../../concepts/clinical/encounter.mdx). Care keeps the current location and +the full location history of the encounter. + +## Pre-requisites + +- The encounter is open. If there is no encounter, + [create an encounter](./create-an-encounter.mdx) first. +- The encounter is not closed. Care blocks updates to a closed encounter. +- An administrator has set up the locations and beds of your facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Read encounter | Open the encounter | +| Update Encounter non clinical | Assign, move, or end the location of the patient | + +## Steps + +### 1. Open the encounter + +From the facility dashboard, select **Encounters**. Select the encounter. + +### 2. Open the location panel + +Select **Assign Location**. The **Update Location** panel opens. + +:::note +The keyboard shortcut **l** opens **Assign Location**. The shortcut **shift+e** opens +the command dialog, which lists every encounter action. +::: + +### 3. Select a location + +Select the **Assign Location** tab. Select the location, then select the bed. + +To find a bed, enter the name of the bed in the search box. To hide the beds that are in +use, turn on the available filter. + +### 4. Confirm the bed + +Select the bed to assign it now, or schedule the bed for a later time. + +If the current patient of the bed leaves soon, Care shows **Confirm Selection**. Select +**Proceed** to take the bed. + +If the bed is in use and the free time is not known, Care shows **Bed Occupied**. Select +**Close**, then select a different bed. + +### 5. Check the history + +Select the **Location History** tab. The tab lists every location of the encounter, with +the newest first. + +## Expected Outcome + +- The encounter shows the new location of the patient. +- Care adds the location to the location history of the encounter. +- Staff who have access to that location can now see the encounter. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/close-an-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/close-an-encounter.mdx new file mode 100644 index 00000000..75b842a7 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/close-an-encounter.mdx @@ -0,0 +1,107 @@ +--- +sidebar_position: 4 +--- + +# How to close an encounter + +## Overview + +This flow describes how to end an +[encounter](../../concepts/clinical/encounter.mdx) when care for the episode is +finished. A closed encounter accepts no new clinical records. + +## Pre-requisites + +- The encounter is open, and the encounter is not closed already. +- Staff record the clinical data of the episode. Care blocks new records after you close + the encounter. +- If the patient occupies a bed, staff end the location stay. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Read encounter | Open the encounter | +| Update Encounter non clinical | Change the status of the encounter and record the discharge details | + +## Steps + +### 1. Open the encounter + +From the facility dashboard, select **Encounters**. Select the encounter. + +### 2. Open the encounter details + +Select **Update Encounter Details**. The encounter form opens. + +:::note +The keyboard shortcut **shift+u** opens **Update Encounter Details**. +::: + +### 3. Discharge the patient + +In the **Discharge Patient** panel, select **Mark for discharge**. Care sets the status +to Discharged. + +Note: After the status is Discharged, you cannot change the status in this form. + +### 4. Record the discharge details + +For an Inpatient, Observation, or Emergency encounter, complete the **Hospitalization +Details** section: + +| Components | What it captures | +| --- | --- | +| Re-admission | Whether the patient returns for the same problem. | +| Admit Source | Where the patient comes from, for example From outpatient department. | +| Discharge Disposition | Where the patient goes, for example Home or Other health care facility. | +| Discharge Date and Time | The time the episode ends. | +| Diet Preference | The diet that the patient needs. | + +Enter the advice for the patient in **Discharge Summary Advice**. + +Note: Your deployment can set the discharge disposition that Care selects first. + +### 5. Complete the encounter + +Select **Mark as Completed** in the encounter actions. Care shows the **Mark as +Complete** dialog. + +If the encounter still needs a discharge, the action shows as **Mark for discharge**. + +Read the message in the dialog. Care can also close the appointment and the token of the +patient. + +Select **Mark as Complete** to confirm. To keep the encounter open, select **Cancel**. + +:::note +The keyboard shortcut **m c** opens the **Mark as Completed** action. +::: + +### 6. Open the discharge summary + +Open the **Reports** panel of the encounter. Select the discharge summary template of +your facility. Care shows the report for the encounter. + +## Expected Outcome + +- The encounter status is Completed. +- Care blocks new clinical records against the encounter. +- The discharge summary advice shows in the summary of the encounter. + +:::note +To reopen a Completed encounter, select **Restart Encounter** in the encounter actions. +Care allows a restart only within the time limit that your deployment sets. +::: + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/create-an-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/create-an-encounter.mdx new file mode 100644 index 00000000..9a162746 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/create-an-encounter.mdx @@ -0,0 +1,95 @@ +--- +sidebar_position: 2 +--- + +# How to create an encounter + +## Overview + +This flow describes how to start an +[encounter](../../concepts/clinical/encounter.mdx) for a patient at your facility. The +encounter is the episode of care that holds the clinical records of the visit. + +## Pre-requisites + +- The patient is registered in Care. If the patient is new, first + [register the patient](../../concepts/clinical/patient). +- You belong to a department of the facility that treats the patient. +- If you start the encounter from an appointment, the patient has a booked or checked-in + appointment at the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Create encounter | Start an encounter for a patient at the facility | +| Can Read encounter | Open the encounter after Care creates it | + +## Steps + +### 1. Open the patient + +From the facility dashboard, select **Patients**. Select the patient. + +### 2. Start the encounter + +Select **Create Encounter**. The **Initiate Patient Encounter** panel opens. + +You can also start the encounter from the **Encounters** tab of the patient. + +To start an encounter from an appointment, open the appointment. Select **Start +Consultation** to begin care now. Select **Create Planned Encounter** to record an +episode that starts later. + +:::note +On the patient page, the keyboard shortcut **e** opens **Create Encounter**. On the +appointment page, **1** starts a consultation and **2** creates an encounter. +::: + +### 3. Enter the encounter details + +Complete the panel: + +| Components | What it captures | +| --- | --- | +| Date and Time | The time the episode starts. Care fills in the current time. | +| Type of Encounter | The kind of episode: Ambulatory, Emergency, Inpatient, Observation, Home Health, or Virtual. | +| Status | Planned, In Progress, or On Hold. | +| Priority | The urgency of the episode, for example Routine, Urgent, or Emergency. | +| Tags | The labels that your facility uses for encounters. | +| Departments | The facility departments that the encounter belongs to. | + +Note: Which types of encounter you can select depends on the configuration of your +deployment. + +A future date is only allowed for a planned encounter. + +### 4. Select a department + +Select at least one department. Care keeps **Create Encounter** disabled until you +select a department. + +Care uses the department to decide who can see and update the encounter. + +### 5. Save the encounter + +Select **Create Encounter**. To cancel the panel, select **Cancel**. + +## Expected Outcome + +- Care shows the message "Encounter created successfully". +- Care opens the **Updates** tab of the new encounter. +- The encounter shows in the **Encounters** tab of the patient. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) diff --git a/versioned_sidebars/version-3.0-sidebars.json b/versioned_sidebars/version-3.0-sidebars.json index 5376f674..995480ce 100644 --- a/versioned_sidebars/version-3.0-sidebars.json +++ b/versioned_sidebars/version-3.0-sidebars.json @@ -21,7 +21,12 @@ "type": "category", "label": "Clinical", "key": "clinical-flows", - "items": ["flows/clinical/create-patient"] + "items": [ + "flows/clinical/create-patient", + "flows/clinical/create-an-encounter", + "flows/clinical/assign-a-location-to-an-encounter", + "flows/clinical/close-an-encounter" + ] } ] }, @@ -37,4 +42,4 @@ ] } ] -} +} \ No newline at end of file diff --git a/versioned_sidebars/version-3.1-sidebars.json b/versioned_sidebars/version-3.1-sidebars.json index 42537320..d7c23c46 100644 --- a/versioned_sidebars/version-3.1-sidebars.json +++ b/versioned_sidebars/version-3.1-sidebars.json @@ -37,7 +37,10 @@ "flows/clinical/patient/manage-patient-users", "flows/clinical/patient/view-patient-appointments" ] - } + }, + "flows/clinical/create-an-encounter", + "flows/clinical/assign-a-location-to-an-encounter", + "flows/clinical/close-an-encounter" ] } ] @@ -54,4 +57,4 @@ ] } ] -} +} \ No newline at end of file