Patient Visit Summary / Printable Visit Documentation - Seeking Community Feedback

Community
1

Hi OpenMRS Community,

I’m working on a Printable Patient Visit Summary and would love to get your feedback, particularly from implementers and clinicians who might use this in practice.

The goal is to create a printable visit summary that serves dual purposes:

  • Patient-facing: Personal records, insurance claims, continuity of care

  • Provider-facing: Referrals, discharge documentation, care coordination

Questions for the Community

  1. What data elements are essential in your context? See data mapping table in attached images.

  2. How do you handle incomplete data? e.g., pending lab results?

  3. Customization needs: What level of configurability do you need? See the sample template.

  4. Print workflow: Should print be accessible under the visit app or where else do you think is the most appropriate location?

Sample Template
Sample Template778×1036 101 KB

Print location
Print location1174×644 62 KB

Patient Visit Summary data elements
Patient Visit Summary data elements1880×1366 233 KB

Looking forward to your insights, requirements and suggestions.

Detailed Requirements can be found here.

cc: @burke @grace @mmwanje @michaelbontyes @jnsereko

2 Likes
2
  1. Header (facility & visit context) Facility name/code, clinic/location Printed by, print timestamp Date range of the report (start date / end date)
  2. Patient demographics & risk flags Full name, identifiers (e.g., MRN, national ID, insurance number) Sex, DOB/age, phone, address
  3. Programs / enrollments & triage Programs / enrollments (HIV, NCD, MCH, TB, etc.) Date enrolled / exited
  4. Clinical notes & diagnoses Allergies Conditions (active / inactive) Previous visits Visit type (OPD / ED / IPD / ANC, etc.) Encounter date Triage Notes Medications Primary / secondary diagnosis Attending clinician (name / ID) and signature line
  5. Orders & results Lab: orders placed during the visit; key results with value, reference range, date, status Imaging / procedures
  6. Medications Active medications (drug, dose, route, frequency, duration, quantity, instructions)
  7. Appointments Follow-up appointment (date / time, location, reason)
  8. Billing summary (optional) Payer/insurance, authorization/reference Line items (code, qty, price), totals (subtotal, discounts, due, paid, balance)

This is generic since each implementation will choose what key variable they would like to track and can build up on this.

Incomplete data (orders)

We can attach status of orders Ordered , In-Progress ,Completed , Canceled alternatively have – or Missing.

Customization

  • This is inevitable since a HIV summary and say an OPD referral for specialized care will require different level of details, under each heading a users should be able to remove or add variables.
  • The summary should be in the patient chart so that we keep it role based (Patient Summary section), For insurance a patient summary can be printed from billing.
  • There should be provision for branding the header with a logo and preferred colours
  • Localization
1 Like
3

Thank you @wamz for this comprehensive and thoughtful feedback on the patient visit summary.

I’d like to better understand the rationale for including previous visit types (OPD/ED/IPD/ANC, etc.), given that the primary goal is to document the current visit summary.

This feels closer to a full clinical report than a visit summary.

Are you suggesting 2 different summaries - one for billing and another for the patient events/services

Yes, i agree regarding the customization.

1 Like
4

A few areas to consider

  1. On conditions - Have a separate tab for chronic illnesses
  2. Under medications—include active medications (mainly focusing on lifetime drugs for chronic illnesses)
  3. Consider adding a section on allergies and adverse reactions
2 Likes