OPD-Visit-Report.md

OPD Visit Report

• OPD = Outpatient Department

1. This report is created at completion of an outpatient visit. Its primary purpose is to inform the patient of the outcome of the visit, and to provide a record for any future appointments. It is not needed by OPD personnel per se, since all the information on the report is already in the system.
2. Ideally, the report is created with a simple click on a visit page. There is no need to prevent duplicate reports being created for a single visit.
3. It is the responsibility of the OPD personnel (including receptionist and/or cashier) to ensure that all required information relative to the visit, has been recorded in the system, prior to creating the report.
4. The visit report DOES NOT serve as a prescription form, although any Med orders requested by the doctor during the visit are to be noted on the report.
5. The report can also serve as a type of Admissions Form, to be presented by the patient upon return for an admission visit.

Notes:

• A different report, (Discharge Report) is used for visits of type admission

Jobs to be Done (JTBD)

When: A patient if ready for OPD check-out (Receptionist)

I want to:

1. Review the vist information for completeness and accuracy
2. Make or request any updates or additions to the visit information
3. Review any appointments with the patient
4. Generate the OPD visit report to give to the patient
5. Review the highlights of the report with the patient
6. Check-out the patient, thereby closing the visit.

So I can: Efficiently and effectively conclude the OPD visit for the patient, ensuring all information is accurate.

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Data Elements

Notes:

This report can be suplemented with a custom form.

####OPD Visit Report

Note: fields below are given in the top to bottom order on the page.

1. Patient ID
2. Patient First Name
3. Patient Last Name
4. Patient Sex
5. Patient Age and D.O.B.
6. Date of (this) Visit
7. Visit Type
8. Visit Examiner
9. Visit Location
10. Active Diagnosis, primary and secondary, from the visit.
11. OPD Procedures Performed during visit (if applicable)
12. Lab orders requested (if applicable
13. Images taken: Image type (if applicable)
14. Meds ordered (regardless of whether or not they were fufilled)
15. Next Appointments dates and types (if applicable)
16. Fields from Operative Plan (if an active plan is present, else leave blank)
    1. Operation Description
    2. List of procedures planned
    3. Instructions upon Admission
17. Notes
18. Custom Form Fields