Medical case basics: the patient's clinical record
Understand what a case is, why it matters, and how it works in Usystems.
What is a medical case?
A medical case is a patient's clinical record within a single visit or admission to a healthcare ward or clinic. It holds all the medical information related to that encounter: vital signs, symptoms, diagnoses, treatment notes, procedures, prescriptions, and related financial services (if charged).
In Usystems, a case is the central place where clinical staff record and track patient care during a visit. Once a patient is queued (checked in), a case can be opened to capture their medical encounter from start to finish.
Why cases matter
Medical cases serve two critical functions:
-
Clinical continuity. Your staff have a complete record of what happened during the visit—what was examined, what was diagnosed, what was done—so follow-up appointments and future care can be informed.
-
Financial tracking. Services and procedures recorded in a case can be billed automatically, ensuring no clinical work goes unrecorded in the financial system. This keeps your accounts accurate and your revenue complete.
How cases work in Usystems
A case is linked to:
- A patient. The case belongs to one patient only.
- A queue or direct admission. A case can be opened from a queue token (a checked-in patient waiting to see a doctor) or directly if the patient arrives without queuing.
- A ward or department. The case is recorded within the context of the clinic or ward (OPD, IPD, Emergency, etc.), which determines available fields and workflows.
- An admission date and time. The case records when the encounter started. An inpatient case may also record a discharge time.
Once open, a case can contain:
- Vital signs (temperature, blood pressure, weight, etc.)
- Chief complaint and history of present illness
- Examination notes and findings
- Diagnoses
- Treatment plans and clinical notes
- Procedures and services rendered
- Prescriptions
- Referrals to specialists or other wards
All of this information stays in the case unless explicitly archived or deleted.
Where you see cases in Usystems
View and create cases from Medical Cases in the main menu. You can also open a case directly from a patient's profile or from a queue token if your role permits.
Open Medical Cases in Usystems
Manage settings and permissions for cases (which custom fields appear, who can see what) under Settings → Medical Cases (if available to your role).
For urgent situations, cases in Emergency Ward or IPD follow the same structure but may have additional fields (such as injury type or admission reason) specific to inpatient or emergency care.
Was this helpful?