Purpose:
This article guides you on how to document snakebite services. It aims to standardize the documentation process, ensuring that all relevant patient information is accurately recorded and easily accessible. By following this SOP, healthcare providers can ensure timely and appropriate patient care, facilitate continuity of care, and support data collection for quality improvement initiatives. Additionally, this SOP aims to streamline workflows and reduce the risk of errors in patient records.
Follow the step for documenting Cervical Cancer Screening service in Outpatient:
Log in Outpatient.
Search for the patient file. You can search for the patient file using any of the following methods:
Visits - This shows you a list of all visits for the day. If patients are not checked out in the system, the visit automatically gets checked out after 24 hours.
All Visits - Here you can search for patients using Phone number or Evax ID only. It shows you patient visit history.
Recent Activity - This shows you a list of files that you have recently opened and the time you accessed the file.
Go to the visit screen and click the plus icon on services to add a VMMC service.
HISTORY TAB
Previous Treatment Section
External Facility - Select the facility that the patient was attended before coming to the site
Arrived with Tourniquet - Select Yes if the patient arrived with a device that stops blood flow.
Home Remedy or Traditional Treatment - Select Yes if there are home remedies or traditional treatment given to patient before getting to the facility.
Snake Section
Snake Brought in or Photo Shown - Select Yes if snake was brought or a photo of it was brought for easy identification.
Snake Color - Enter the color of the snake.
Estimated Length / Width (cm) - Enter the estimated length and width of the snake.
Snake Type - Enter the name of the snake. It is advised to know the correct name of the snake as this will help with prescribing the correct antivenom.
Bite Section
Bite Date Time - Enter the date when patient got bitten.
Bite Location - Enter the body area that got bitten. Be more specific
Bite Circumstances - Enter the reason that caused to the bite
Bite Site Circled with Permanent Marker - Select Yes if you have circled the bitten area that's bitten.
Distance of Bite Site to Furthest Point of Swelling (mm) - measure in millimeters the distance between the site that was bitten and the last point of swelling.
Circumference Affected Limb (mm) - Measure the circumference of the affected limb.
Circumference unaffected Limb (mm) - Measure the circumference of the unaffected limb,
Complaints Section
Enter the complaints that the patient is suffering from.
PHYSICAL EXAM TAB
Physical Exam Section
Do a physical a physical assessment to the patient.
If there is any part that looks abnormal, Click 'Abnormal' then write the description.
PLAB TAB
Management Plan Section
Management Plan - Select the plan from the provided list.
Management Plan Comments - Add the plan comments. This include the may include the medication to be administered and on going monitoring.
SERVICE PROVIDER
Click "Select Service provider" link, followed by clicking by clicking "Set As Me" to show your name as the service provider.
SERVICE REVIEW
Finally .click the "Submit Review" button to send the service template for review.