General - Primary Care Visit – Adult Injury & Td Booster

Purpose

The General / Primary Care Visit is used when a patient presents for non-scheduled, general clinical care that does not fall under a dedicated carepath (such as ANC or Healthy Baby / Child).

This visit type supports a wide range of real-world clinical scenarios, including:

• Minor injuries and wound care

• Walk-in consultations

• Follow-up care

• Opportunistic immunization (e.g., Td booster)

In this example, the workflow documents an adult patient with a minor injury where a Td (Adult) booster is clinically indicated.

This page explains how to:

• Search for and open a patient record

• Start a General / Primary Care Visit

• Review demographics and existing conditions

• Use Visit Actions to record immunizations and clinical services

• Save, pause, or discharge the visit correctly

---

Navigation

From the sidebar, expand Patients and select Search.

• Search for the patient using one or more identifiers (name, national ID, barcode).

• Open the View Patient page.

• Review demographic details for accuracy.

• Select Start Visit to begin a new encounter.

---

Workflow

1

Start the General / Primary Care Visit

From the patient dashboard, select Start Visit.

When prompted to choose a visit type:

• Select General / Primary Care Visit

This visit type is designed for flexible, unscheduled care and does not automatically enroll the patient into a programmatic carepath.

2

Review Demographics and Active Conditions

Once the visit opens, review:

• Patient demographics

• Existing Active Conditions (e.g., pregnancy status, HIV status, chronic conditions)

Update or add conditions if new information is identified during the encounter.

Accurate condition data ensures appropriate clinical decision support and future care behaviour.

3

Review Pre-Populated Visit Actions

For a General / Primary Care Visit, certain items may appear automatically under Visit Actions based on system configuration and patient profile.

Common pre-populated Visit Actions include:

• Td (Adult)

• HIV Status

These items appear automatically and do not need to be manually added.

Review each item and determine whether it applies to the current visit.

4

Required Visit Action — HIV Status

HIV Status is a required Visit Action for General / Primary Care visits.

This means:

• HIV Status must be completed before the visit can be ended.

• The system will block End Visit if HIV Status is left incomplete.

• This requirement applies even if no immunization is given.

What to do:

1. Open the HIV Status row.

2. Select the appropriate value (e.g., Known Positive, Known Negative, Unknown).

3. Click Complete.

If HIV status is not known or testing was not performed during the visit, select Unknown. Do not leave the action incomplete.

5

Record the Td Booster (Visit Actions)

The Td booster can be recorded either as given today or back-entered, depending on when it was administered.

Visit Actions – Complete (Given Today)

Use this option when the Td booster is administered during the current visit.

• Open Td (Adult) under Visit Actions

• Enter all required fields:

  • Lot #

  • Syringe Type (ADS 0.5 mL)

  • Administration Site

• Click Complete to save

Back-Entry (Previously Given)

6

Add Additional Clinical Services (Optional)

Use Visit Actions → Add to record additional services relevant to the encounter.

Available actions may include:

• Vital Signs

• Blood Pressure Reading

• Body Temperature

• Height Entry

• Weight Entry

• Immunization (Booster / Ad Hoc)

• Supplements

• Pregnancy Status

• Pregnancy History

• Pregnancy Completion / Termination

• Sexually Transmitted Infectious Disease

• Adverse Event Following Immunization (AEFI)

• Death Report

Select only those actions that are clinically relevant to the visit.

7

Save, Pause, or Return to Waiting Room

If additional care is required or the visit must remain open:

• Click Save to preserve all completed actions

• Select Return to Waiting Room if the patient is awaiting further services

Available statuses may include:

• Checked In

• Awaiting Specialist Care

• Awaiting IMCI Care

• Awaiting Vaccination

Best Practice — Saving and Security

• Save frequently to avoid data loss due to timeout

• Always save before stepping away from the tablet

• Lock the tablet if unattended

8

End the Visit and Discharge the Patient

When care is complete:

1. Select End Visit

2. Confirm all required Visit Actions are completed

3. Select an appropriate Discharge Reason

   • Commonly: Discharged to home or self-care – routine discharge

4. Complete the discharge to close the encounter

---

Key Notes

• General / Primary Care Visits support flexible, unscheduled care

• HIV Status is mandatory and must be completed before ending the visit

• Td (Adult) and HIV Status are typically pre-populated Visit Actions

• ADS 0.5 mL syringe must always be recorded for Td administration

• Back-Entry should be used only for historical doses

• Always confirm a Discharge Reason to finalize the visit

---

Summary

The General / Primary Care Visit allows clinicians to safely document unscheduled adult care, including injury assessment and Td booster administration. By reviewing pre-populated Visit Actions, completing required items such as HIV Status, recording immunizations accurately, and properly discharging the visit, staff ensure high-quality clinical documentation and reliable public health data.

---