101.4 Record Visits

The standard fields associated with a visit include:

1. Visit date

2. Status: (Complete, Pending, Missed, Not Collected)

3. Visit Site

4. Clinical Diagnosis (multiple select): ICD 10 codes

5. Clinical Status

   Open

   

This process is recommended if collecting clinical data at the time of specimen collection. Note that any of the visit information can be edited at a later date.

1. This Visit page can be accessed during the collection process using the Collect Visit feature. Choose ‘Visit’ from the ‘Collect’ button in the Pending Visit table on the Participant overview page.

2. Open

   

3. This navigates to the Visit page.

   1. Clinical Diagnoses can be entered in one of two ways. Multiple diagnoses may be chosen.

      1. Typing any part of the description of the clinical disease will display the matching choices in the dropdown.

      2. Typing the ICD 10 code will display the matching diagnosis. Note: OpenSpecimen uses ICD 10 diagnosis codes to record clinical disease descriptions which enables data querying and manipulation across studies.

      3. Example: typing ‘diabetes’ will display all subtypes of any ICD 10 containing ‘diabetes’.

   2. Clinical Status can be used to record if a participant is a No Diagnosis / Control or to record their clinical status as related to the specific study. Each study will choose their own usage of these terms.

   3. Cohort currently records only Case vs. Control. If your study has different designations for Cohort, these can be recorded with a custom field.

   4. Surgical Pathology Number may be entered, if available.

   5. Comments is a text field available for free typing.

4. Visit data are saved by selecting:

   1. ‘Create’ directs the user to the Visit overview page where details can be viewed and reviewed and edited if necessary; OR

   2. 'Proceed to Collection' directs the user to the Planned Specimen Collection page.

5. ‘Create’ navigates to the Visit Overview Page which displays the Visit details and the specimen table. All specimens will appear as ‘Pending’ (noted by the yellow dot next to the description).

6. If there are multiple visits, each visit will have its own Overview Page and its own forms attached if any are attached at the Visit Level.

   1. For each visit, the menu bar on the left shows 4 tabs and defaults to ‘Overview’:

       

       

   2. If a Path Report is available as a .pdf, it may be uploaded from the Path Report tab.

   3. If Form-specific data is to be entered, any attached forms can be accessed from the Forms tab. (As as example, patient’s medications usually change over time and a different form can be completed at each visit for medications.)

   4. The Specimen tree tab functions as it does for Participants, by displaying the the specimen tree on the left side of the screen being viewed.

Editing Clinical data after specimen collection

It is common that clinical diagnoses or pathology is not obtained until after specimen collection occurs. If this is the case, the Clinical information can be added or updated at any time using ‘Edit’ on the Visit page.

1. The Visit page can be accessed after collection by selecting the ‘Event Label’ in the ‘Occurred Visits’ table.

2. Choose ‘Edit’ for the Completed Visit.

3. Edit or update any fields as described above.

To skip the step of recording clinical data about the visit, navigate directly to the Specimen Collection.

• By choosing 'Proceed to Collection' upon registering a participant, the Visit page will be skipped and you will be navigated directly to the planned specimen collection page for the visit chosen.

• Navigate to the Participant overview for an existing participant. Choose ‘Specimens’ from the ‘Collect’ button on the Pending Visits table.