CC-UC-01700 - Primary Health Care: Basic Flow - Clinical Documents After Procedure

Actors

• Client/client caregiver
• Medical Administrator
• Registered Nurse
• Medical doctor (MD)/nurse practitioner (NP)

Pre-conditions

• The client is covered under the provincial health care insurance.
• The client is an existing patient at the clinic.
• The MD performed a medical procedure on the client at the clinic (Top procedures in primary care are structure removal, joint injection, pap test, laceration repair).

Step	Description	Data elements collected	Result
1	MD/NP documents the completed medical procedure. This may include, but is not limited to, the procedure performed, post-procedure instructions and care plan, and follow-up plan.	Document Date and Time Document Status Document Type Document Author Role Document Principal Author Document Contributing Author Document Recipient Document Content	The completed medical procedure is documented, and the client's medical record is updated.
2	The medical administrator schedules a follow-up appointment as directed by MD/NP .	Appointment Services by Appointment Only Flag Appointment Service Category Appointment Service Type Appointment Creation Date and Time Appointment Requested Range Appointment Priority Appointment Expected Duration Appointment Reason Appointment Instructions Appointment Confirmation Status Appointment Attendance Requirement Appointment Participation Period Appointment Period Appointment Specialty Appointment Type Appointment Cancellation Date and Time Appointment Rescheduled Date and Time Appointment Cancellation Reason Appointment Rescheduled Flag	A follow-up appointment is scheduled and recorded in the client's medical record.
3	This use case ends.	Not applicable	Not applicable

Post-conditions

• Clinical documents are completed and recorded in the medical record.
• The completed medical procedure is documented.
• A follow-up appointment scheduled.
• Client's medical record is updated.

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Contact us

If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca