Case details and custom fields (extra fields)
A reference guide to standard and custom fields that appear on a medical case.
Standard case fields
Every case contains these core fields:
| Field | Meaning | Notes |
|---|---|---|
| Patient | Name and ID of the patient | Auto-filled when case is opened; cannot change. |
| Admission date/time | When the patient was checked in | Defaults to the current date and time; may be editable depending on your role. |
| Discharge date/time | When the patient left (IPD/Emergency only) | Empty on admission; filled in when the patient is discharged. For OPD cases, often left empty or used to record the end time of the visit. |
| Ward/Department | Which clinic, ward, or department the case belongs to | Examples: OPD (outpatient), IPD (inpatient), Emergency Ward, Dental. Determines which custom fields appear. |
| Case status | Current state of the case | Examples: Open, Closed, On hold. Controls who can edit the case and whether new items can be added. |
| Chief complaint | The main reason the patient came in | Short description (e.g., "chest pain," "fever," "wound check"). Often a required field. |
| Notes | General clinical notes | Free text for examiner to record observations, history, or follow-up instructions. |
Custom fields
Beyond the standard fields above, your ward may have custom fields configured by your administrator. These fields vary by ward/department and are set up to match your clinical needs. Examples include:
| Field | Possible values | Ward | Purpose |
|---|---|---|---|
| Referral source | OPD self-referral, walk-in, referred from hospital, referred from doctor | Any | Track how the patient arrived and who referred them. |
| Admission reason | Acute illness, chronic follow-up, procedure, emergency | IPD, Emergency | Classify the admission type. |
| Attending doctor | List of available doctors | Any | Assign the case to the doctor in charge. |
| Priority | Routine, urgent, emergency | Emergency, IPD | Set the clinical urgency. |
| Injury type | Blunt, penetrating, burn, fracture, etc. | Emergency | For trauma cases, record the injury category. |
| Isolation status | None, contact precautions, droplet, airborne | IPD | For infection control. |
| Triage level | Level 1 (Critical), Level 2 (Urgent), Level 3 (Semi-urgent), Level 4 (Non-urgent) | Emergency | Standard emergency triage classification. |
How custom fields are managed
- Who sets them up? Your system administrator or IT team configures custom fields in Settings → Medical Cases (or equivalent).
- Which fields appear? The set of custom fields shown on a case form depends on the selected Ward/Department. Switching wards may show or hide fields.
- Are they required? Administrators can mark custom fields as required or optional. If a field is required, you must fill it before you can save the case.
- Can I edit them later? Yes, in most cases. Once a case is created, you can usually edit its fields unless the case is locked or archived.
Adding and editing case information
After a case is created, you can add to it:
- Vital signs (temperature, blood pressure, pulse, weight, etc.) — usually recorded in a dedicated section or linked view.
- Diagnoses — recorded separately from the chief complaint; often classified by status (provisional, confirmed, etc.).
- Procedures and services — linked to the case so they can be billed.
- Prescriptions — medicines and instructions for the patient.
- Clinical notes — additional observations, treatment plans, referrals.
Most of these are added through dedicated sections or forms within the case view, not directly in the main case fields.
Viewing case history
Once created, cases are usually immutable records—old entries cannot be deleted (to maintain audit trail), but new information is always added. If you need to correct a recorded item, ask your administrator whether amendments are allowed or whether a new, corrected entry should be added instead.
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