diff --git a/versioned_docs/version-3.0/concepts/clinical/encounter.mdx b/versioned_docs/version-3.0/concepts/clinical/encounter.mdx index 442c5f5f..f5574870 100644 --- a/versioned_docs/version-3.0/concepts/clinical/encounter.mdx +++ b/versioned_docs/version-3.0/concepts/clinical/encounter.mdx @@ -4,74 +4,74 @@ 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)** 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. The encounter is the working context for clinical activity: Care gathers the observations, orders, medicines, and notes of that episode under it. One [patient](../clinical/patient) has many encounters over time, so the patient record is the chart and each encounter is a dated chapter in it. -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. +## Key Attributes -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. - -## 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 | +| --- | --- | +| Type of Encounter | The kind of interaction, such as Inpatient or Ambulatory | +| Encounter Status | The point the episode has reached | +| Priority | The urgency of the episode, such as Routine or Emergency | +| Date and Time | The start of the episode, and the end after the episode closes | +| Departments and Teams | The departments of the facility that are responsible for the episode | +| Care Team | The users who look after the patient in this episode, each with a role | +| Location | The place in the facility that the patient occupies now, with the full location history | +| Hospitalization details | For an admission, the admit source, the discharge disposition, the diet preference, and whether the patient is re-admitted | +| Tags | Labels that your facility applies to group encounters | +| Encounter ID | An identifier from an external system, when your deployment sends one | + +### Type of Encounter + +| Type | 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 or telehealth consultation | +| Home Health | Care provided at the patient's home | -```text -planned ──▶ in_progress ──▶ discharged ──▶ completed - ▲ │ - └───┘ on_hold (pause, then resume) -``` +The type and the priority are set apart from each other. An admission can be Routine, and an outpatient visit can be an Emergency. Care keeps a history of each change of type. -- **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 +:::note +Your deployment decides which types staff can select, and which type is offered first. +::: -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 Team -## Classification +The care team lists the users who look after the patient in this episode. Each member holds a clinical role, and one member can be marked as primary. A user must have access to the encounter before you can add that user to the care team. -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. - -## Permissions +| Planned | The episode is scheduled but has not started | +| In Progress | Staff see or treat the patient now | +| On Hold | Care is paused, for example while the patient waits for a bed | +| Discharged | The patient has left the facility | +| Completed | The episode is finished | +| Cancelled | The episode was called off before care started | +| Discontinued | The episode was stopped and does not resume | +| Entered in error | The encounter was created by mistake | +| Unknown | The status of the episode is not known | -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 records every change of status with the time of the change, so the episode stays auditable. -| 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 | +Completed, Cancelled, Discontinued, and Entered in error are the closed statuses. A closed encounter accepts no new clinical records. Staff with permission to update the encounter can reopen a closed encounter with **Restart Encounter**. -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. +:::note +Your deployment sets a time limit for a restart, and a maximum number of open encounters for one patient in one facility. +::: ## Related -- Reference: [Encounter (technical)](../../references/clinical/encounter.mdx) +- Flow: [Create an encounter](../../flows/clinical/create-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: [Observation](../clinical/observation.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..85766382 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/assign-a-location-to-an-encounter.mdx @@ -0,0 +1,69 @@ +--- +sidebar_position: 4 +--- + +# How to assign a location to an encounter + +## Overview + +This flow describes how to record the place in the facility that the patient occupies during an [encounter](../../concepts/clinical/encounter.mdx). Care keeps the full location history of the encounter. + +## Pre-requisites + +- The encounter is open, and you record the location for that encounter. +- Your administrator has set up the locations and the beds of the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Assign a location to the encounter | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Open the location panel + +Open the **Actions** panel, then select **Update Location**. + +The **Update Location** panel opens on the **Assign Location** tab. + +### 3. Select the location + +Select the location, then select the bed. + +Care shows the beds that are free, the beds that are held, and the beds that another patient occupies. + +### 4. Confirm the assignment + +Select **Assign bed now** to move the patient to the bed now. + +Select **Schedule for later** to plan the bed for a later time. + +Select **Add reserved bed** to hold the bed for the patient. + +## Expected Outcome + +- The encounter shows the new location of the patient. +- Care adds the change to the location history of the encounter. +- Select the **Location History** tab of the panel to read the full history. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-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..1d9da76d --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/close-an-encounter.mdx @@ -0,0 +1,82 @@ +--- +sidebar_position: 3 +--- + +# How to close an encounter + +## Overview + +This flow describes how to close an [encounter](../../concepts/clinical/encounter.mdx) when the episode of care ends. A closed encounter accepts no new clinical records. + +## Pre-requisites + +- The encounter is open, and you record the completion for that encounter. +- You recorded the clinical information of the episode, because a closed encounter accepts no new records. +- If the encounter is an Inpatient encounter, you complete the discharge details first. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Change the status of the encounter to Completed | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Select the close action + +Open the **Actions** panel on the overview page. + +For an Inpatient encounter that is not yet Discharged, the panel shows **Mark for discharge**. For every other encounter, the panel shows **Mark as Completed**. + +### 3. Record the discharge details + +Follow this step only for an Inpatient encounter that is not yet Discharged. + +Select **Mark for discharge**. Care opens the encounter questionnaire and sets the status to Discharged. + +| Components | What it captures | +| --- | --- | +| Discharge Disposition | Where the patient goes after the facility | +| Discharge Summary Advice | The advice that the patient takes home | +| Diet Preference | The diet of the patient during the admission | +| Re-Admission | Whether this admission repeats an earlier one | + +Select **Submit**. Care records the end of the episode. + +Return to the **Actions** panel, then select **Mark as Completed**. + +### 4. Confirm the completion + +Care asks you to confirm. Select **Mark as Complete**. + +If the encounter comes from an appointment, Care warns that the action also closes the appointment and the token. + +## Expected Outcome + +- The status of the encounter changes to Completed, and Care records the end time. +- Care confirms with the message "Encounter Completed". +- The encounter accepts no new clinical records. +- If the encounter comes from an appointment, Care closes the appointment and the token. +- Staff with permission to update the encounter can reopen it with **Restart Encounter**, within the time limit that your deployment sets. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-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..ff400d15 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/create-an-encounter.mdx @@ -0,0 +1,91 @@ +--- +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 becomes the working context for the clinical records of that episode. + +## Pre-requisites + +- The patient is registered in Care, and you open the encounter for that patient. +- You are a member of the facility, and of at least one department in it. +- If you start the encounter from an appointment, the patient has a booked or a checked-in appointment at the facility. +- If the patient already has open encounters at the facility, the number of open encounters is below the limit that your deployment sets. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Create encounter | Create an encounter for a patient at the facility | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the patient + +Select **Patients** in the facility menu. Search for the patient, then select the patient. + +The patient home page opens. + +### 2. Start the encounter + +Select **Create Encounter**. Press E on the patient home page for the same result. + +The **Initiate Patient Encounter** panel opens. + +If you start from an appointment, open the appointment and select **Create Encounter** there. Care links the encounter to that appointment. + +### 3. Describe the episode + +Complete the fields in the panel. + +| Components | What it captures | +| --- | --- | +| Date and Time | The start of the episode. A future date is allowed only for a Planned encounter | +| Type of Encounter | Inpatient, Ambulatory, Observation, Emergency, Virtual, or Home Health | +| Status | Planned, In Progress, or On Hold | +| Priority | The urgency of the episode, for example Routine or Emergency | +| Tags | Labels that your facility applies to group encounters | +| Department | The department that is responsible for the episode | + +:::note +Your deployment decides which types of encounter staff can select, and which type is offered first. +::: + +### 4. Select a department + +Select **Select Department**, then select at least one department of the facility. + +The departments you select decide who can see and act on the encounter. + +### 5. Save the encounter + +Select **Create Encounter**. + +Care confirms with the message "Encounter created successfully", and opens the encounter. + +## Expected Outcome + +- Care creates the encounter with the status you selected. +- Care opens the updates page of the encounter. +- The encounter accepts observations, orders, medicines, and notes. +- If you started from an appointment, Care links the appointment to the encounter. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Create a patient](../../flows/clinical/create-patient) +- [Close an encounter](./close-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-an-encounter.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/manage-the-care-team-of-an-encounter.mdx b/versioned_docs/version-3.0/flows/clinical/manage-the-care-team-of-an-encounter.mdx new file mode 100644 index 00000000..5e6fe85d --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/manage-the-care-team-of-an-encounter.mdx @@ -0,0 +1,73 @@ +--- +sidebar_position: 5 +--- + +# How to manage the care team of an encounter + +## Overview + +This flow describes how to record the users who look after the patient during an [encounter](../../concepts/clinical/encounter.mdx). Each member of the care team holds a clinical role. + +## Pre-requisites + +- The encounter is open, and you record the care team for that encounter. +- Each user you add is a member of a department that has access to the encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Add a member to the care team, or remove a member | +| Can Read encounter | Read the care team of the encounter | + +Admin, Doctor, Nurse, and Facility Admin hold these permissions. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Open the care team panel + +Open the **Actions** panel, then select **Manage Care Team**. + +The **Manage Care Team** panel opens. + +### 3. Add a member + +Select **Select Department**, then select the department of the user. + +Select **Select Member**, then select the user. + +Select **Select Role**, then select the clinical role of the user. + +Select **Add**. Care confirms with the message "Member added successfully". + +### 4. Set the primary member + +Select **Mark as Primary** beside the member who leads the care of the patient. + +### 5. Remove a member + +Select **Remove** beside the member. Care asks you to confirm, then removes the member. + +## Expected Outcome + +- The overview page of the encounter lists the members of the care team with their roles. +- The primary member carries the Primary label. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) diff --git a/versioned_docs/version-3.0/references/clinical/encounter.mdx b/versioned_docs/version-3.0/references/clinical/encounter.mdx index aeaca19f..3fce71e2 100644 --- a/versioned_docs/version-3.0/references/clinical/encounter.mdx +++ b/versioned_docs/version-3.0/references/clinical/encounter.mdx @@ -4,7 +4,9 @@ sidebar_position: 2 # Encounter -An `Encounter` records a single interaction between a patient and a facility — a visit, admission, or consultation — and maps to the FHIR `Encounter` resource. You create one when a patient presents, drive it through its status lifecycle, and read it back to render the clinical timeline. +Technical reference for the `Encounter` module in Care EMR. For the plain-language view, read the [Encounter](../../concepts/clinical/encounter.mdx) concept. + +An `Encounter` records a single interaction between a patient and a facility — a visit, admission, or consultation. You create one when a patient presents, drive it through its status lifecycle, and read it back to render the clinical timeline. The Django model is only the storage layer: several fields are opaque `JSONField`s whose real shape lives in the Pydantic resource specs, so the model alone won't tell you what a write must look like. The spec tables below carry that detail. diff --git a/versioned_docs/version-3.1/concepts/clinical/encounter.mdx b/versioned_docs/version-3.1/concepts/clinical/encounter.mdx index 442c5f5f..f5574870 100644 --- a/versioned_docs/version-3.1/concepts/clinical/encounter.mdx +++ b/versioned_docs/version-3.1/concepts/clinical/encounter.mdx @@ -4,74 +4,74 @@ 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)** 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. The encounter is the working context for clinical activity: Care gathers the observations, orders, medicines, and notes of that episode under it. One [patient](../clinical/patient) has many encounters over time, so the patient record is the chart and each encounter is a dated chapter in it. -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. +## Key Attributes -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. - -## 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 | +| --- | --- | +| Type of Encounter | The kind of interaction, such as Inpatient or Ambulatory | +| Encounter Status | The point the episode has reached | +| Priority | The urgency of the episode, such as Routine or Emergency | +| Date and Time | The start of the episode, and the end after the episode closes | +| Departments and Teams | The departments of the facility that are responsible for the episode | +| Care Team | The users who look after the patient in this episode, each with a role | +| Location | The place in the facility that the patient occupies now, with the full location history | +| Hospitalization details | For an admission, the admit source, the discharge disposition, the diet preference, and whether the patient is re-admitted | +| Tags | Labels that your facility applies to group encounters | +| Encounter ID | An identifier from an external system, when your deployment sends one | + +### Type of Encounter + +| Type | 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 or telehealth consultation | +| Home Health | Care provided at the patient's home | -```text -planned ──▶ in_progress ──▶ discharged ──▶ completed - ▲ │ - └───┘ on_hold (pause, then resume) -``` +The type and the priority are set apart from each other. An admission can be Routine, and an outpatient visit can be an Emergency. Care keeps a history of each change of type. -- **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 +:::note +Your deployment decides which types staff can select, and which type is offered first. +::: -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 Team -## Classification +The care team lists the users who look after the patient in this episode. Each member holds a clinical role, and one member can be marked as primary. A user must have access to the encounter before you can add that user to the care team. -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. - -## Permissions +| Planned | The episode is scheduled but has not started | +| In Progress | Staff see or treat the patient now | +| On Hold | Care is paused, for example while the patient waits for a bed | +| Discharged | The patient has left the facility | +| Completed | The episode is finished | +| Cancelled | The episode was called off before care started | +| Discontinued | The episode was stopped and does not resume | +| Entered in error | The encounter was created by mistake | +| Unknown | The status of the episode is not known | -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 records every change of status with the time of the change, so the episode stays auditable. -| 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 | +Completed, Cancelled, Discontinued, and Entered in error are the closed statuses. A closed encounter accepts no new clinical records. Staff with permission to update the encounter can reopen a closed encounter with **Restart Encounter**. -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. +:::note +Your deployment sets a time limit for a restart, and a maximum number of open encounters for one patient in one facility. +::: ## Related -- Reference: [Encounter (technical)](../../references/clinical/encounter.mdx) +- Flow: [Create an encounter](../../flows/clinical/create-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: [Observation](../clinical/observation.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..85766382 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/assign-a-location-to-an-encounter.mdx @@ -0,0 +1,69 @@ +--- +sidebar_position: 4 +--- + +# How to assign a location to an encounter + +## Overview + +This flow describes how to record the place in the facility that the patient occupies during an [encounter](../../concepts/clinical/encounter.mdx). Care keeps the full location history of the encounter. + +## Pre-requisites + +- The encounter is open, and you record the location for that encounter. +- Your administrator has set up the locations and the beds of the facility. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Assign a location to the encounter | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Open the location panel + +Open the **Actions** panel, then select **Update Location**. + +The **Update Location** panel opens on the **Assign Location** tab. + +### 3. Select the location + +Select the location, then select the bed. + +Care shows the beds that are free, the beds that are held, and the beds that another patient occupies. + +### 4. Confirm the assignment + +Select **Assign bed now** to move the patient to the bed now. + +Select **Schedule for later** to plan the bed for a later time. + +Select **Add reserved bed** to hold the bed for the patient. + +## Expected Outcome + +- The encounter shows the new location of the patient. +- Care adds the change to the location history of the encounter. +- Select the **Location History** tab of the panel to read the full history. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-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..1d9da76d --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/close-an-encounter.mdx @@ -0,0 +1,82 @@ +--- +sidebar_position: 3 +--- + +# How to close an encounter + +## Overview + +This flow describes how to close an [encounter](../../concepts/clinical/encounter.mdx) when the episode of care ends. A closed encounter accepts no new clinical records. + +## Pre-requisites + +- The encounter is open, and you record the completion for that encounter. +- You recorded the clinical information of the episode, because a closed encounter accepts no new records. +- If the encounter is an Inpatient encounter, you complete the discharge details first. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Change the status of the encounter to Completed | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Select the close action + +Open the **Actions** panel on the overview page. + +For an Inpatient encounter that is not yet Discharged, the panel shows **Mark for discharge**. For every other encounter, the panel shows **Mark as Completed**. + +### 3. Record the discharge details + +Follow this step only for an Inpatient encounter that is not yet Discharged. + +Select **Mark for discharge**. Care opens the encounter questionnaire and sets the status to Discharged. + +| Components | What it captures | +| --- | --- | +| Discharge Disposition | Where the patient goes after the facility | +| Discharge Summary Advice | The advice that the patient takes home | +| Diet Preference | The diet of the patient during the admission | +| Re-Admission | Whether this admission repeats an earlier one | + +Select **Submit**. Care records the end of the episode. + +Return to the **Actions** panel, then select **Mark as Completed**. + +### 4. Confirm the completion + +Care asks you to confirm. Select **Mark as Complete**. + +If the encounter comes from an appointment, Care warns that the action also closes the appointment and the token. + +## Expected Outcome + +- The status of the encounter changes to Completed, and Care records the end time. +- Care confirms with the message "Encounter Completed". +- The encounter accepts no new clinical records. +- If the encounter comes from an appointment, Care closes the appointment and the token. +- Staff with permission to update the encounter can reopen it with **Restart Encounter**, within the time limit that your deployment sets. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-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..6aeaffff --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/create-an-encounter.mdx @@ -0,0 +1,91 @@ +--- +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 becomes the working context for the clinical records of that episode. + +## Pre-requisites + +- The patient is registered in Care, and you open the encounter for that patient. +- You are a member of the facility, and of at least one department in it. +- If you start the encounter from an appointment, the patient has a booked or a checked-in appointment at the facility. +- If the patient already has open encounters at the facility, the number of open encounters is below the limit that your deployment sets. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can Create encounter | Create an encounter for a patient at the facility | + +Admin, Doctor, Nurse, and Facility Admin hold this permission. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the patient + +Select **Patients** in the facility menu. Search for the patient, then select the patient. + +The patient home page opens. + +### 2. Start the encounter + +Select **Create Encounter**. Press E on the patient home page for the same result. + +The **Initiate Patient Encounter** panel opens. + +If you start from an appointment, open the appointment and select **Create Encounter** there. Care links the encounter to that appointment. + +### 3. Describe the episode + +Complete the fields in the panel. + +| Components | What it captures | +| --- | --- | +| Date and Time | The start of the episode. A future date is allowed only for a Planned encounter | +| Type of Encounter | Inpatient, Ambulatory, Observation, Emergency, Virtual, or Home Health | +| Status | Planned, In Progress, or On Hold | +| Priority | The urgency of the episode, for example Routine or Emergency | +| Tags | Labels that your facility applies to group encounters | +| Department | The department that is responsible for the episode | + +:::note +Your deployment decides which types of encounter staff can select, and which type is offered first. +::: + +### 4. Select a department + +Select **Select Department**, then select at least one department of the facility. + +The departments you select decide who can see and act on the encounter. + +### 5. Save the encounter + +Select **Create Encounter**. + +Care confirms with the message "Encounter created successfully", and opens the encounter. + +## Expected Outcome + +- Care creates the encounter with the status you selected. +- Care opens the updates page of the encounter. +- The encounter accepts observations, orders, medicines, and notes. +- If you started from an appointment, Care links the appointment to the encounter. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Register a patient](../../flows/clinical/patient/register-patient.mdx) +- [Close an encounter](./close-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) +- [Manage the care team of an encounter](./manage-the-care-team-of-an-encounter.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/manage-the-care-team-of-an-encounter.mdx b/versioned_docs/version-3.1/flows/clinical/manage-the-care-team-of-an-encounter.mdx new file mode 100644 index 00000000..5e6fe85d --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/manage-the-care-team-of-an-encounter.mdx @@ -0,0 +1,73 @@ +--- +sidebar_position: 5 +--- + +# How to manage the care team of an encounter + +## Overview + +This flow describes how to record the users who look after the patient during an [encounter](../../concepts/clinical/encounter.mdx). Each member of the care team holds a clinical role. + +## Pre-requisites + +- The encounter is open, and you record the care team for that encounter. +- Each user you add is a member of a department that has access to the encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Update Encounter non clinical | Add a member to the care team, or remove a member | +| Can Read encounter | Read the care team of the encounter | + +Admin, Doctor, Nurse, and Facility Admin hold these permissions. Your administrator grants a role to you through a department of the facility. + +## Steps + +### 1. Open the encounter + +Select **Patients** in the facility menu. Select the patient, then select the encounter. + +The overview page of the encounter opens. + +### 2. Open the care team panel + +Open the **Actions** panel, then select **Manage Care Team**. + +The **Manage Care Team** panel opens. + +### 3. Add a member + +Select **Select Department**, then select the department of the user. + +Select **Select Member**, then select the user. + +Select **Select Role**, then select the clinical role of the user. + +Select **Add**. Care confirms with the message "Member added successfully". + +### 4. Set the primary member + +Select **Mark as Primary** beside the member who leads the care of the patient. + +### 5. Remove a member + +Select **Remove** beside the member. Care asks you to confirm, then removes the member. + +## Expected Outcome + +- The overview page of the encounter lists the members of the care team with their roles. +- The primary member carries the Primary label. + +## Related + +Concepts: + +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Create an encounter](./create-an-encounter.mdx) +- [Close an encounter](./close-an-encounter.mdx) +- [Assign a location to an encounter](./assign-a-location-to-an-encounter.mdx) diff --git a/versioned_docs/version-3.1/references/clinical/encounter.mdx b/versioned_docs/version-3.1/references/clinical/encounter.mdx index aeaca19f..3fce71e2 100644 --- a/versioned_docs/version-3.1/references/clinical/encounter.mdx +++ b/versioned_docs/version-3.1/references/clinical/encounter.mdx @@ -4,7 +4,9 @@ sidebar_position: 2 # Encounter -An `Encounter` records a single interaction between a patient and a facility — a visit, admission, or consultation — and maps to the FHIR `Encounter` resource. You create one when a patient presents, drive it through its status lifecycle, and read it back to render the clinical timeline. +Technical reference for the `Encounter` module in Care EMR. For the plain-language view, read the [Encounter](../../concepts/clinical/encounter.mdx) concept. + +An `Encounter` records a single interaction between a patient and a facility — a visit, admission, or consultation. You create one when a patient presents, drive it through its status lifecycle, and read it back to render the clinical timeline. The Django model is only the storage layer: several fields are opaque `JSONField`s whose real shape lives in the Pydantic resource specs, so the model alone won't tell you what a write must look like. The spec tables below carry that detail. diff --git a/versioned_sidebars/version-3.0-sidebars.json b/versioned_sidebars/version-3.0-sidebars.json index 5376f674..50325c86 100644 --- a/versioned_sidebars/version-3.0-sidebars.json +++ b/versioned_sidebars/version-3.0-sidebars.json @@ -21,7 +21,13 @@ "type": "category", "label": "Clinical", "key": "clinical-flows", - "items": ["flows/clinical/create-patient"] + "items": [ + "flows/clinical/create-patient", + "flows/clinical/create-an-encounter", + "flows/clinical/close-an-encounter", + "flows/clinical/assign-a-location-to-an-encounter", + "flows/clinical/manage-the-care-team-of-an-encounter" + ] } ] }, @@ -37,4 +43,4 @@ ] } ] -} +} \ 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..d42dec6a 100644 --- a/versioned_sidebars/version-3.1-sidebars.json +++ b/versioned_sidebars/version-3.1-sidebars.json @@ -37,7 +37,11 @@ "flows/clinical/patient/manage-patient-users", "flows/clinical/patient/view-patient-appointments" ] - } + }, + "flows/clinical/create-an-encounter", + "flows/clinical/close-an-encounter", + "flows/clinical/assign-a-location-to-an-encounter", + "flows/clinical/manage-the-care-team-of-an-encounter" ] } ] @@ -54,4 +58,4 @@ ] } ] -} +} \ No newline at end of file