Start a visit and write the note

After this lesson you can start a visit, write its note and find it again if you leave it open. It takes about 15 minutes. You need write access to the patient's clinical records.

Why it matters

A visit is the working note for one contact with a patient. An appointment only reserves time. A phone call with no booking can still have a visit.

A visit stays open, and unsigned, until you sign it. It is easy to leave one behind, so Salisan shows you where your open visits are.

How it works

Anna de Vries arrives for her follow-up. Her doctor opens her record and starts a visit.

Start the visit

Choose Start visit in the patient bar. The note opens at once, with a type chosen for you: the type of today's appointment, otherwise the type you last started for this patient, otherwise In practice. To pick another, open the arrow beside the button and choose In practice, Home visit, Phone consultation or Video consultation.

If Anna has an appointment today, the appointment line on the Record page offers Start visit too. That starts a visit linked to the booking.

Salisan names the note after the visit type and the date. Click the title to rename it.

A patient has one open visit at a time. While one is open, the patient bar shows Continue visit instead of Start visit, so you return to the same note.

Write the note

Write the facts of the contact in the note. Anna's doctor types: "Follow-up for blood pressure. Home readings brought in. No new complaints."

The note saves as you type. Watch the indicator: Saving…, then Saved. It reads Unsaved changes while text has not reached the server. Saved means the words are stored. It does not put anything in the patient's record. That comes in the next lesson.

Type / in the note to add more than text. The menu offers blocks such as Diagnosis, Medication, Allergy, Blood pressure and Transcribe audio.

Find an open visit again

Salisan keeps pointing to a visit that is still open:

• A chip such as Unsigned · 2h appears in the patient bar, beside Start visit and New.
• The Record page says Your visit is unsigned.
• To sign appears in the sidebar with the number of your unsigned visits. Its queue lets you read and sign them one after another.
• The patient's Visits page lists every visit.

Start with the patient's own Visits page when you look for an earlier contact.

Try it

Use the test patient Sam Testpatient from the first lesson. If you do not have one, create it as described in Learn.

1. Open Sam's record and choose Start visit. If you pick the type yourself, open the arrow and choose In practice.
2. Click the title and rename the note to "Learning visit".
3. Write two sentences, for example "Test visit for training. Nothing clinical." Wait until the indicator reads Saved.
4. Open the Record page again from the patient's name. Find the chip that starts with "Unsigned" and the line Your visit is unsigned.
5. Look at the patient bar. It now shows Continue visit where Start visit was. Choose it to return to the note.
6. Find To sign in the sidebar. The number shows your unsigned visits.
7. In the note, type / and read the menu without choosing anything. Press Escape.

Leave the visit open for the next lesson.

Check yourself

1. A patient phones you and no appointment exists. Can you document the call?

Answer

Yes. Open the arrow beside Start visit and choose Phone consultation. A visit does not need an appointment.

2. The indicator reads Unsaved changes. What do you do before you close the tab?

Answer

Wait until it reads Saved. Until then the latest words may not be stored.

3. Where do you find the visits you have not signed?

Answer

Under To sign in the sidebar, in the unsigned chip on the patient's pages, and on the patient's Visits page.

Next

Continue with Record findings and sign a note. For the full steps, see Visits and notes.