Visit Information Tab

The Visit Information tab displays all episode/visit information on a patient.  It is also the primary place for entering medical information for the current visit to the hospital. 

Episodes

The Patient Record - Visits Information tab is broken down by Episodes - a discrete visit that begins at the moment the patient is checked in, and ends when the patient is discharged.  

Episodes that have been created but for which the patient has not been checked in are considered pre-admissions (New) and will appear on the Visit Information tab with a large PA symbol.

Episodes for which the patient has been checked in are Open. 

Episodes remain open until the patient is Discharged.

Episodes should remain discharged until all the documentation is completed, at which point they may be Closed.  

VetView supports electronic medical record auditing through the Medical Records Management screen, so your school may prevent you from closing a record until all the documents inside have been completed and verified.

Medical Record Groups

A Medical Record Group is a collection of parts of the record, or categories.  Think of these as virtual sub-folders inside each episode:  If the whole patient record was a physical medical record, then the Patient Summary tab would be the outer cover, and the folders inside would be episodes, with dividers indicating each Medical Record Category. 

As soon as an episode is created, regardless of the status that it is in, the episode's record groups will be available based on the Episode Type.

Additional record groups will be created throughout the episode as you add documents and requests.   If the Episode Type changes, then additional required medical record groups can appear based on the new minimum requirements set by your hospital.  (For example, if an Outpatient type is changed to Surgery, then a Surgery document category may appear.)

Adding Content to An Episode

There are two ways to add items to the episode: from the episode header, or from the right click "context menus" available on the episode.

Via the Header

A context menu is a menu that changes depending on what part of the medical record you are clicking, or the status of the episode.

For example, a pre-admission will have a Check In button, but fewer options otherwise.

Once an episode is opened, more items become available via the header.

Via Right Click

The Right Click context menu will list all the available options for the episode when you click on the header, including hidden admin features if you have the privileges to see them.

Context Menus are available depending on which parts of the medical record you are working with.  Context menus open up via a right click.

Detailed View of Medical Record Categories and Visit Information Sections

For more detailed information about each of the Medical Record Categories, visit the links below.

• Episode Filters Panel
• Episode Context Menu
• Episode Context Menu in 5.0
• Billing Section
• Episode Documents
• Episode Documents in 5.0
• Episode Requests
• Episode Personnel
• Episode Problems and SOAPs
• Episode Problems and SOAPs in 5.0
• Episode Diagnosis in 5.0
• Medication Section
• TPR / Vitals and View Past TPR Results
• TPR / Vitals and View Past TPR Results in 5.0
• Patient Record Communication Log