--- title: "IPD Case Sheet" description: "Collapsible day-by-day inpatient record — treatment chart, vitals, doctor and nurse notes, orders, procedures, documents, and diagnostic report trends." date: 2026-09-05 lastModified: 2026-09-13 category: "ipd" author: "Dr. Umesh Bilagi" beta: true --- ## Overview The **case sheet** is the electronic, day-by-day record of an inpatient admission. It replaces the handwritten paper case sheet by bringing the treatment chart, vitals, doctor and nurse notes, orders, procedures, documents, and diagnostic-report trends into one screen, organised per day and printable. The case sheet is built from the admission's `Encounter` and the FHIR records created against it. It is read as a stream of per-visit notes — there is no separate progress-note module; the case sheet *is* the running record. ## Prerequisites - The patient must have an active **inpatient admission** (an `Encounter` with class `IMP`). See [IPD Admission](/docs/ipd-admission). - You must have a role that can view the case sheet: **admin**, **director**, **doctor**, **nurse**, or **visitor**. - Only users linked to a **practitioner** (doctors) can add **Doctor Notes**; nurses and other users add **Nurse Notes**. ## Where to find it 1. Open the patient's record from **Doctor Patient Management**. 2. Click the **Case Sheet** link. The page header shows the patient name, encounter, and patient ID, with a **Print** button to open the printable case sheet and a **Refresh** button to reload the latest data. ## Panels The case sheet is a set of **collapsible sections** (accordions) that toggle independently. The **Treatment Chart** is open by default; the rest start collapsed so long admissions don't produce an endless scroll. Click a section header to expand or collapse it. Sections appear top to bottom: ### 1. Treatment Chart A tabular chart of the patient's medicines. The **Add Medicine** pop-up captures the medicine, its frequency (e.g. `TID`, `BD`), route (e.g. `Oral`), and duration (e.g. `5 days`). Each medicine can then be ticked off per dose as it is administered. ### 2. Vitals Routine vitals recorded day by day — blood pressure, pulse, GCS score, and other inpatient vitals. Vitals are entered via a pop-up and grouped per day. ### 3. Notes Doctor and nurse notes grouped by day, shown **side by side** — a **Doctor Notes** column on the left and a **Nurse Notes** column on the right. The author and time appear under each note. - **+ Doctor Note** — visible only to users linked to a practitioner (doctors). Opens a pop-up to enter the note text. - **+ Nurse Note** — available to any clinical user. Opens the same pop-up. - Notes are entered as free text and saved as `ProgressNote` (doctor) or `NurseNote` (nurse) records. - The **Discharge Summary** is not shown here — it is available under **Documents** (below). ### 4. Orders Investigations and service requests (e.g. `X-ray chest`), added via the **Add Order** pop-up. Each order is tracked through to execution, so you can see which orders have been carried out. ### 5. Procedures Procedures performed during the admission (e.g. `Wound dressing`), added via the **Add Procedure** pop-up. ### 6. Documents Links that open in a new tab: - **Discharge Summary** — the signed summary PDF for the admission. - **Lab Trends** — a PDF of all diagnostic-report tables and trend graphs. - **Descriptive reports** (e.g. a CT scan or other narrative report) — each links to its own printable report PDF. ### 7. Diagnostic Reports The admission's diagnostic results, grouped into **panel-wise tables** (tests as rows, collection date with Morning / Evening / Night sub-columns). Quantitative (`Qn`) tests additionally render as a **line graph** — one graph per panel, with all numeric tests overlaid and each line using a distinct dash pattern so it stays readable in black-and-white print. A **Print lab trends** button opens the same tables and graphs as a separate PDF. Only reports scoped to the current admission are shown. ## Editing and permissions - **View** the case sheet — admin, director, doctor, nurse, visitor. - **Add** notes, vitals, medicines, orders, and procedures — admin, director, doctor, nurse. Visitors can create service requests (orders) but not notes, vitals, or medicines. - **Edit or delete** a past note — restricted to the **main consultant** of the admission (the attending practitioner) plus **admin** and **director**. The edit and delete actions only appear for users who pass this gate, and a note is not edited in place — a superseding version is created with a full audit trail. Nurses have no practitioner resource of their own, so their notes are attributed to the organisation rather than an individual practitioner. ## Common Issues - **"+ Doctor Note" button is missing** — the button only appears when your account is linked to a practitioner. Nurses should use **+ Nurse Note** instead. - **No Edit/Delete on a note** — you must be the main consultant (or an admin/director) to edit past notes. - **Case sheet is empty** — the patient may not have an active inpatient encounter, or no notes have been recorded yet. ## FAQ **Q: Is the case sheet the same as the discharge summary?** A: No. The case sheet is the running day-by-day record of the admission. The discharge summary is the single signed document produced at discharge. **Q: Who can edit a note after it is saved?** A: Only the main consultant of the admission, plus admins and directors. Edits create a superseding version rather than overwriting the original. **Q: Can a nurse add a doctor note?** A: No. Doctor notes require a practitioner link. Nurses add **Nurse Notes** instead.