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 whom 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 will cover how to enter clinic visits. For more information on setting up clinic visits, click here.
To create a new clinic visit:
- Go to School Main > Health Records > Clinic Visits
- Create Clinic Visit
- In the General section, enter information for the following fields. Any fields marked with an asterisk (*) are mandatory:
- Visit type: Add a visit type to categorize the clinic visit
- Visit Date: Enter the date the student visited the nurse and the time in and out
- Released to: If the student was released to another party, enter that here
- Parent/Communication: If the contact was notified of the visit, select the correct communication method
- Notes: Include any other relevant information
- Under Subjective Reasons, select the student’s main complaint(s) and enter any notes
- Under Objective Measurements, enter observed or other collected data, such as vitals signs:
- Nurse Observations: Choose an option and click “select” to add to the list of observations. Click “Remove” to remove an observation
- Notes: Include any other relevant information
- Pain Level: Enter the student’s pain at the beginning and end of the visit using the in and out fields
- Temp: Enter the student’s temperature in Fahrenheit
- Blood Pressure: Enter the student’s blood pressure, measured as systolic pressure / diastolic pressure in units of mm Hg
- Respiratory Rate: Enter the number of breaths per minute
- Pulse Rate: Enter the student’s heart rate as beats per minute
- Oxygenation: Enter the student’s blood oxygenation as a percent value
- Labs: Include any relevant labs
- Under Assessments, select your assessment(s) of the clinic visit and enter any notes.
- In the Plan/Medications section, enter the action used to treat the student:
- Plans: Choose an option and click “select” to add to the list of plans. Click “Remove” to remove a plan
- Notes: Include any other relevant information
- Medicine Administered: If the student has medication on profile and the medication was administered during the visit, you can enter the medication information here.
- Click the checkbox to consent that you have reviewed the information for accuracy, and you are solely responsible for any actions taken
- Save