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
- Click 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. For more information on administering medicine, please refer to the following article.
- Click the checkbox to consent that you have reviewed the information for accuracy, and you are solely responsible for any actions taken
- Click Save
For steps on how to generate reports related to this data, please refer to the following article.