Recording Procedures

Overview

The Procedures module in SehaFile documents clinical procedures performed during a visit. Each procedure record captures the procedure name (Arabic and English), optional CPT code for billing standardization, clinical notes, and the associated cost. Procedures feed directly into the billing system for invoice generation and are tracked in the patient's medical history.

Steps to Record a Procedure

1. Open the visit workspace — Navigate to the active visit.
2. Scroll to the Procedures section — Click + Add Procedure to expand the form.
3. Enter the procedure name — Type in the procedure_name_ar field (required). The field autocompletes from your clinic's procedure catalog (managed in Settings > Procedures Catalog).
   • Optionally fill procedure_name_en for bilingual documentation
4. Enter the CPT code (optional) — If your clinic uses CPT coding for insurance claims, enter the code (e.g., “99213” for outpatient visit, “12001” for wound closure).
5. Add clinical notes — Document relevant details about how the procedure was performed, any complications, or specific techniques used.
6. Set the cost — The cost auto-fills from the catalog's default_cost but can be overridden. This amount is included in the visit invoice.
7. Click “Add Procedure” — The procedure is saved to the visit (POST /visits/:id/procedures).

Managing Procedures

• View procedures — All recorded procedures for the visit appear in a list with name, cost, and CPT code
• Remove a procedure — Click the delete button next to any procedure (DELETE /visits/:id/procedures/:procId)

FAQ

Can I record a procedure not in the catalog?

Yes. The procedure name is a free-text field. Catalog entries provide autocomplete convenience but are not required.

How do procedures affect billing?

Each procedure's cost is added to the visit total when generating an invoice. The invoice lists procedures separately from the consultation fee.

Who manages the procedures catalog?

Clinic administrators manage the catalog at Settings > Procedures Catalog, setting names, specialties, CPT codes, costs, and active/inactive status.