Clinic visits are used to track student visits to the nurse’s office. There are five major sections a nurse can complete when entering a clinic visit. The General section gives the visit type and date as well as who the student was potentially released to and if there was parent/guardian communication. The other four sections can be abbreviated using the acronym SOAP:
- Subjective Reasons: A student’s reasons for going to the clinic
- Objective Measurements: A nurse’s observations during a clinic visit
- Assessments: A nurse’s diagnosis for a clinic visit
- Plans: Treatment plans based on the assessments in a clinic visit
This article explains how to set up the options a nurse can select when completing these five sections for a clinic visit.
This article will cover the following topics:
For more information on creating clinic visits please read How do I Enter Clinic Visits?
Configuring SOAP and General Sections
Setting up options works the same way for visit types, assessments, etc. Below, we will list instructions to add a subjective reason, but you can use the same steps for the other options as well.
To Add a Subjective Reason:
- Go to School Main > Health Records > Subjective Reasons
- Create Subjective Reason
- Enter a Description
- Save
The process for adding a pain level is different, as they can be sorted by order of severity if desired.
To Add a Pain Level:
- Go to School Main > Health Records > Pain Levels
- Create Pain Level
- Enter a Description
- Enter its List Order in the Insert Above field
- Save
Updating a Clinic Visit option
If an option needs to be changed, you have the ability to edit it. Once an option has been used in a clinic visit, we discourage making changes, as it will change the option for all previous clinic visits as well. We would instead advise making the option inactive and creating a new option for future use. Below, we will list instructions to edit or make a subjective reason inactive. You can use the same steps for the other options as well.
To Update a Subjective Reason:
- Go to School Main > Health Records > Subjective Reasons
- Select Edit for the option that needs to be updated
- (Optional) Update the Description
- (Optional) Update the Active status
- Save