IPD Case Sheet

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 doctor and nurse notes, treatment chart, orders, procedures, and vitals into one screen, organised per day and printable as a single document.

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.
• You must have a role that can view the case sheet: admin, director, doctor, or nurse.
• 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 Refresh button to reload the latest data.

Panels

The case sheet is a single page with five panels, shown top to bottom:

1. Notes

Doctor and nurse notes grouped by day. Each day shows three sub-sections — Doctor Notes, Nurse Notes, and Discharge Summary — with the author and time 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.

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. 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.

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.

Editing and permissions

• View the case sheet — admin, director, doctor, nurse.
• Add notes, vitals, medicines, orders, and procedures — admin, director, doctor, nurse.
• 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.