Visit summary

Summary

The „Summary” tab is used to closing visit.

In case of unfinished NFZ’s visits in POZ, AOS, rehabilitation, psychiatry, therapy and stomatology in the "Summary" tab there is displayed a form to indicate services reported to the NFZ. Within POZ it is a list that allows to choose single service that can be settled (if in the application’s configuration there was defined a default service, then it is automatically selected with the ability to change; if synonyms are defined for services in the dictionary of NFZ services, then they are displayed instead of names of services; if in the dictionary of NFZ services it is marked that some services should not be displayed, then they will be omitted from the drop-down list). In addition, in POZ, if the results of diagnostic examination from budget entrusted have been registered in the system, then it is possible to mark the examinatoins discussed during the visit - such marked examinations will be automatically coded as services for reporting to the National Health Fund. The coding of benefits provided and vaccinations is analogous. If the patient's chronic diseases have been registered in the "Chronic dis." tab, then in the "Summary" tab in POZ, it is additionally possible to select the field groups of chronic diseases with which the given patient's visit was related - diagnoses for the first chronic disease for each of the selected field groups will be automatically coded next to the service/services for reporting to the National Health Fund. Within AOS it is a list that allows to choose single service that can be settled (the system limits the list of services to choose from to those that fit the procedures performed by the doctor), in case of gynekology preceded by the list of pregnancy weeks. In the case of ASDK, it is also possible to indicate a second (additional) service - anesthesia. In addition, the AOS displays fields that allow you to enter information for the referring physician, which is required for first-time services (filling in these fields results in the display of a piece of paper next to the patient's name after closing the visit, on a navy blue background, enabling the information for the referring physician to be printed on the form provided for this). Within rehabilitation, psychiatry and therapy it is a list of services possible to be settled and by each of them there is checkbox field (allowing to point out services to be settled) and a list of procedures (allowing to point out procedure appropriate for the given service). Within stomatology it is a list of services possible to be settled and by each of them there is checkbox field (allowing to point out services to be settled) and a list of teeth codes (allowing to point out tooth code appropriate for the given service). The form to indicate services reported to NFZ is available only for the main staff realizing a visit / surgery.

For all the (unfinished) visits (except hospital stays) in the "Summary" tab is displayed a form allowing to do entry to the book of surgeries, in which the doctor inserts a note about the type of performed surgery and its progress (the remaining data are inserted automatically to the book of surgeries). This form is available only for the main staff realizing a visit / surgery.

In case of unfinished operations in the operating room there is displayed a form in the "Summary" tab to make an entry to the book of operational block or operational room, where the doctor inserts a note of type and proceeding of made operation / surgery, a detailed description of the operation / surgery, ICD-10 code of diagnosis of pre-operative and post-operative, ordered diagnostic tests and the type and description of given anesthesia to the patient (other data to the book of surgeries are inserted automatically). This form is available only for the main staff realizing a visit / surgery.

In case of unfinished visits in the emergency room, in the "Summary" tab there is displayed a form of making an entry to the book of refusals of admissions and outpatient advices provided in the emergency room (if the visit in the emergency room ends with the refusal of admission to hospital). The entry the book of refusals of admissions and outpatient advices provided in the emergency room requires to enter some data manually (other required data will be inserted automatically). In case of refusal of admission to the hospital, if the reason for refusal is lack of consent of the patient to stay in hospital, you should print a note about the lack of patient’s consent for such a stay (by clicking on the printer icon at the "No consent of the patient to stay in hospital" field) and give it to the patient for signing - depending on whether the patient agrees to sign a note or not, this should be noted by selecting the appropriate value in the "No consent of the patient to stay in hospital" field (printed annotation, regardless of whether it has been signed by the patient or not, retain for control purposes). This form is available only for the main staff realizing a visit / surgery.

In case of not finished occupational medicine visits other than main within the tab of “Summary” there is visible form for making note into book of given consultations for occupational medicine purposes, where doctor enters consultation range.

In case of commercial visits (except hospital stays), in the "Summary" tab is also available pricelist of services, in which the doctor notes the services realized during the visit and uncheck services which was pointed by registrar at arranging visit, but they have not been realized. This pricelist is available only for the main staff realizing a visit / surgery. For services for which it is defined that their implementation requires the use of specific resources, fields appear to indicate the resources used. If for the service it has been specified that a given resource should be shown from 2 to 3 pieces, then two fields will be surrounded by a blue border as required to be filled, and one gray as optional. To select the right resource, start entering the serial number in the field next to the resource and then select the resource from the list of hints (you can also press the down arrow button on the keyboard after placing the cursor in the field, and then the list of hints with all available resources will be displayed). Depending on the system configuration, in addition to the field marking the service as performed, the field marking the service as free may also be displayed - selecting this field results in a change of the service price to PLN 0. If the service planned to be performed as part of the visit is (co)financed by the payer, then for such a service, instead of the price from the clinic's price list, the unit amount of the patient's surcharge is displayed, moreover, for such a service it is not possible to check the "Free" box or change the multiplicity.

In the lower part of the tab there are "Back", "Summary" and "End visit" buttons (the last two are only visible to the main staff performing the visit for visits carried out by more than one staff member). "Back" button allows you to switch to the previous tab in the visit card. The "Summary" allows you to preview the summary of the visit and print them. Summary contains all the information entered by the physician in particular tabs of the visit’s window. Depending on system configuration, summary printout pages can be non-numbered or numbered. Pages numbering is automatical (page numbering occurs when the "End visit" button is clicked and the numbering is updated each time when the summary of the visit is downloaded as a PDF file - be it by the doctor when printing the summary, or by registration in the "EHR" tab in the patient's card or by the patient when downloading a medical history of visit within the patient portal) and continuous through all visits of the given patient within the given clinic (consecutive visits summaries of the given patient within the given clinic gain pages numbering so that patient medical documentation had continuous numbering. If there occurs situation when doctor removes something from already realized visit so that summary would shorten (number of summary pages would decrease), then while printing summary again at its end there will be added empty but numbered pages to keep correct continuity of pages numbering for medical documentation. If however there occurs situation when doctor adds something to already realized visit so that summary would lenghten (number of summary pages would increase), then additional pages of this summary will gain numbers created as number of last page of primary summary concatenated with dot and number of additional page (for example if summary had three pages with numbers 1, 2, 3 and doctor added some informations to visit so that number of summary pages lenghtened to five pages, then summary pages would have numbers 1, 2, 3, 3.1, 3.2). Also depending on the system configuration at the time of printing the summary, it can be automatically signed with a doctor's certificate and saved (in the form of a signed PDF file) in the appropriate directory on the server.

The "End visit" button saves forms data filled in the "Summary" tab and changes the status of the visit from agreed to realized (the button "End visit" is available only for the main staff realizing a visit / surgery). If visit is pre-paid and if at least one of realized services within the commercial services dictionary has specified coresponding diagnostic examination, then while ending visit there is order for this diagnostic examination automatically generated (if visit is post-paid and if at least one of realized services within the commercial services dictionary has specified coresponding diagnostic examination, then generation of an order is postponed to the time when full amount of payments for visit is collected). After the visit, view in the "Summary" tab changes in such a way that forms disappear (and therefore disappears the possibility of entering information) and disappears "End visit" button. Moreover, if e-prescriptions / e-referrals have been issued during the visit and the system has been configured to send notifications about them to patients, then when the visit is closed, SMS messages with access codes to the issued e-prescriptions / e-referrals are sent to the patient. If, when making an appointment, the patient has been entered into the admission schedule / waiting queue (NHF), then when closing the visit, he or she is automatically deleted from the schedule / queue, and if the schedule / queue requires it, the system automatically sends a message to AP-KOLCE about removing from the queue due to performance of the service.

After closing the window of visit, there is again displayed a view of prearranged visits. Window of completed (realized) visit can be opened again by clicking on the button with the name of the patient, but in case of realized visits, there is no possibility of modifying the list of realized services during the visit, and all changes made in any of the tab of window of visits are saved.