> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Nursing Care and Procedures
> How nurses use the nursing task checklist and clinical procedure records to document the hands-on care they deliver during each home visit.
When a nurse visits a patient at home, two types of records capture what they did: Nursing Tasks (a checklist of individual steps completed during the visit) and Clinical Procedures (a record of a specific care procedure, like a wound dressing). Together, these give the care business a complete picture of exactly what was done, in what order, and how long each step took.
***
## Before You Start
* Nursing Checklist Templates must be set up by the administrator.
* Clinical Procedure Templates must be set up for each type of procedure (e.g., "Wound Dressing (Home Visit)").
* You need the **Nursing User** role to create and complete nursing tasks and procedures.
***
## Part 1: Nursing Tasks
### What Is a Nursing Task?
A nursing task is a single action on a checklist. Each task has:
* A description of what needs to be done (e.g., "Clean wound with saline")
* A start time (automatically recorded when the nurse marks it as started)
* An end time (automatically recorded when the nurse marks it as completed)
* A status: Initiated / In Progress / Completed
The task start and end times give the care business a log of exactly how long each step took, which is useful for billing time-based care and for monitoring the quality of care delivery.
### Setting Up a Nursing Checklist Template
The administrator sets up checklist templates once. Each template is a list of tasks for a particular type of visit.
1. Go to Home Care workspace → Nurse section → **Nursing Checklist Template** → New
2. Give the template a name (e.g., "Wound Dressing Checklist")
3. Add each task:
| Field | What to Enter |
| --------- | ------------------------------------------------------------------------------------ |
| Activity | The task description (e.g., "Remove old dressing", "Clean wound with Normal Saline") |
| Mandatory | Tick this if the task must be completed before the procedure can be marked as done |
| Category | The type of task (Hygiene, Care, Assessment, etc.) |
**Sample Wound Dressing Checklist:**
| Task | Mandatory |
| -------------------------------------------- | --------- |
| Wash hands and put on gloves | Yes |
| Remove old dressing carefully | Yes |
| Inspect wound - note size, colour, discharge | Yes |
| Clean wound with Normal Saline | Yes |
| Apply Betadine Solution | Yes |
| Apply sterile gauze pads | Yes |
| Wrap with bandage roll | Yes |
| Secure with micropore tape | Yes |
| Dispose of waste in disposal bag | Yes |
| Record wound observations | Yes |
| Wash hands | Yes |
### Completing Nursing Tasks During a Visit
1. Go to Home Care workspace → Nurse section → **Nursing Task**
2. Find the task records for today's visits (they are linked to the clinical procedure)
Or, the tasks are automatically created when a clinical procedure is started (linked to the procedure template's checklist).
For each task:
1. When you start the task, the system records the start time
2. Complete the task
3. Mark it as Completed - the system records the end time
***
## Part 2: Clinical Procedures
### What Is a Clinical Procedure?
A clinical procedure is a specific care service performed during a home visit - something more structured than a general nursing check. The most common example in home care is a wound dressing visit.
The procedure record captures:
* Which procedure was performed
* Which patient it was for
* Which nurse performed it
* What supplies were used
* When it started and ended
* The completion status
### Setting Up a Procedure Template
The administrator sets up procedure templates once. Each template defines the procedure, its billing item, and the typical supplies used.
1. Go to Home Care workspace → Consultation section → **Clinical Procedure Template** → New
| Field | What to Enter |
| ----------------------- | ----------------------------------------------------------------------------------------------- |
| Procedure Template Name | Clear name (e.g., "Wound Dressing (Home Visit)") |
| Medical Department | Nursing |
| Rate | The fee for this procedure |
| Item | The billing item linked to this procedure |
| Duration | Expected time in minutes |
| Consume Stock | Tick ON so that supplies are deducted from inventory when the procedure is completed |
| Warehouse | The stock location supplies are taken from |
| Consumable Items | List of supplies used: Sterile Gauze Pads, Betadine Solution, Normal Saline, Bandage Roll, etc. |
The existing template on this site is:
* **Wound Dressing (Home Visit)** - Nursing department - supplies include Betadine Solution
### Recording a Clinical Procedure During a Visit
After the nurse starts a procedure:
1. Go to Home Care workspace → Consultation section → **Clinical Procedure** → New
Or create it directly from the Patient Encounter by adding it in the Procedures section.
2. Fill in the details:
| Field | What to Enter |
| ----------------------- | ------------------------------------------------------------------------- |
| Patient | The patient being cared for |
| Procedure Template | Select "Wound Dressing (Home Visit)" or whichever procedure is being done |
| Healthcare Practitioner | The nurse performing the procedure |
| Patient Encounter | Link to today's visit record |
| Start Date / Time | When the procedure started |
| Medical Department | Nursing |
| Service Unit | The patient's assigned location |
| Consume Stock | ON (supplies will be deducted) |
| Warehouse | Stores |
3. In the **Consumable Items** section, confirm or adjust the supplies used:
The template pre-fills the standard supplies. If the nurse used more or less than usual (e.g., they used two gauze pads instead of one because the wound was large), update the quantities here.
4. Set the status to **In Progress** when the procedure starts.
5. When the procedure is finished, set status to **Completed**.
6. Click **Submit**.
After submission:
* Supplies are automatically deducted from the stock inventory
* The procedure appears in the patient's history timeline
* The procedure becomes available for invoicing
***
## Supplies Used Per Procedure
The system tracks every item of stock consumed during a procedure. This is why the consumable items section matters.
For a standard wound dressing, the typical supplies used are:
| Supply | What It Is |
| --------------------- | --------------------------------------------------------- |
| Gloves (Disposable) | Worn by the nurse during the procedure |
| Cotton Roll | Used for initial cleaning |
| Sterile Gauze Pads | Applied over the wound as the main dressing |
| Betadine Solution | Antiseptic liquid applied to clean the wound |
| Normal Saline (100ml) | Used to irrigate or clean the wound |
| Bandage Roll | Used to hold the dressing in place |
| Tape (Micropore) | Secures the edges of the dressing |
| Scissors / Forceps | Sterile instruments used to handle dressing material |
| Dressing Tray | Sterile tray to keep equipment clean during procedure |
| Waste Disposal Bag | Safe disposal of used dressings and contaminated material |
When these items are deducted from stock after each procedure, the system shows you when stock is getting low so you can reorder before running out.
***
## Field Guide: Clinical Procedure
| Field | What It Contains |
| ----------------------- | ---------------------------------------------------------- |
| Patient | The patient receiving the procedure |
| Procedure Template | The type of procedure being performed |
| Healthcare Practitioner | The nurse doing the procedure |
| Patient Encounter | Linked to today's home visit record |
| Start Date / Time | When the procedure started |
| Completion Date / Time | When the procedure finished |
| Status | Initiated / In Progress / Completed / Cancelled |
| Consumable Items | List of supplies used and quantities |
| Consume Stock | Whether supplies are automatically deducted (should be ON) |
| Warehouse | The stock location supplies come from |
| Invoiced | Ticked when a bill has been created for this procedure |
***
## Best Practices
* Always link the clinical procedure to the Patient Encounter for the same visit - this keeps the records connected and makes it easy to see what happened during a visit
* Update the consumable quantities if you used more or less than the template default - accurate supply tracking helps the admin know when to reorder
* Submit the procedure record before you leave the patient's home - do not leave it in "In Progress" overnight, as this blocks billing and leaves the patient's record incomplete
* If a procedure had to be stopped partway through (patient refused, wound was too painful, unexpected complication), set the status to Cancelled and add a note explaining what happened
***
## Troubleshooting
**Supplies are not being deducted from stock**
Check that "Consume Stock" is ticked ON in the Procedure Template and that a Warehouse is selected. If the procedure has already been submitted without this, the admin will need to manually create a stock entry.
**The procedure is not appearing in the patient's history**
The procedure record has not been submitted. Submitted is different from saved - the nurse needs to click the Submit button.
**The billing item is not auto-filling when invoicing the procedure**
Check that the Clinical Procedure Template has a billing Item linked. Open the template and add the item, then try creating the invoice again.
***
## Related Features
* [Home Visit Record](/health-wellness/homecare-services/home-visit): Procedures are linked to the visit record
* [Patient Monitoring](/health-wellness/homecare-services/patient-monitoring): Observations (wound photos) are recorded alongside procedures
* [Medical Supplies Stock](/health-wellness/homecare-services/medical-supplies): Procedure consumables are tracked from the stock module
* [Billing and Finance](/health-wellness/homecare-services/billing-finance): Completed procedures are billed as line items on the invoice