A visit records one encounter with a client. Use the visit's Workspace to work through the Visit Record sections, charts, files, and client paperwork. Activity shows the related history.
Client: the person and their identity, contact details, and history.
Case: one ongoing concern, such as one pregnancy. Several visits can belong to the same case.
Visit: what happened during one encounter.
An appointment reserves time. Starting a visit records the encounter. Keep follow-up visits for the same concern on the same case; choose a new case for a new concern.
Find the client and confirm their identity.
From the appointment or Visit Board, choose Start Visit when the client arrives.
Follow the case choice or Intake steps shown. Select the existing case when today's visit continues the same concern.
Open the visit's Workspace and select the section you need.
You can also open an existing visit from Care → Visits, the client, or the case.
What you need to do | Where to work |
|---|---|
Check the visit's client, case, date, center, or consultant | General Info |
Record counseling | Counseling |
Record a pregnancy test | Pregnancy Test |
Enter ultrasound findings and send a Doc Alert | Ultrasound, starting with Info |
Record STI testing | STI Tests |
Record benefits provided | Benefits |
Upload ultrasound images or other visit attachments | Files |
Read or write the general visit note | Notes |
See the visit's status/change history | Timeline |
Work on additional charts, client forms, consents, or assessments | Select the item from the workspace's document list |
Sections and actions depend on the work recorded, your center's configuration, and your permissions. A missing section does not mean you should create a duplicate visit.
The Performed indicators describe care actually provided. Optional test and ultrasound sections can depend on those indicators or your visit defaults. Save the correct visit details rather than changing a Performed indicator solely to make a section appear.
In General Info, the Today's Visit was field records how the client came in. It's a dropdown with two options: Appointment and Walk-in. Pick the one that matches how the client arrived, rather than typing it in yourself.
In General Info, the Today's Visit was field records how the client's visit happened. It offers three options:
Appointment: the client was seen for a scheduled appointment.
Walk-In: the client was seen without an appointment.
Virtual: the visit happened by phone, video, or text instead of in person.
Choose Virtual any time a visit is not in person, so your records reflect how care was actually delivered.
The Visit Record's standard fields are edited in their named sections. You do not need to add a custom chart to enter those fields.
Additional charts, client forms, consents, and assessments keep their own document history. Open the document from the workspace list. Use Add to visit for additional work your center allows.
Client forms contain the client's submitted answers. Staff review and apply those answers; they do not rewrite the client's original submission. Historical documents are for context. Open today's visit before recording today's work.
A visit's Visit Type, when set, is what decides which charts open by default and in what order. See Visit Types.
When you add a benefit on the Benefits section of a visit, CoolFocus can fill in a Program automatically if the benefit type is linked to one.
That fill-in only happens when the client holds an active enrollment in that program covering the visit's date. If the client is not enrolled, or their enrollment does not cover that date, CoolFocus leaves Program blank on the benefit rather than assigning a program the client hasn't joined.
A blank Program does not stop the benefit from saving. It still counts on the visit and toward the client's points and history.
If you expected a program to fill in and it did not, check that the client has an active enrollment in that program covering the visit date. See Programs and Classes.
Use the visit's Print or Email action to generate a PDF of what's recorded on the visit. Two document choices are available for a visit:
Visit Record prints the full visit: client and visit details, vitals, pregnancy test, dating, counseling, and notes.
Ultrasound Report prints the ultrasound's measurements, notes, and scan images.
Both documents pull directly from the visit, so they always match what's saved on the Visit Record. Printing or emailing either one adds a compact entry to the client's activity timeline, the same as other printed documents. See Client Records and History.
Because these documents can include ultrasound measurements and other clinical details, printing or emailing them requires the same permission as viewing the client's clinical charts. A user or group without that permission won't see these options. See User Groups: What Staff Can Open and Change.
Open the correct visit, then Workspace → Files.
Choose Upload files.
In File under, select Ultrasound.
Choose the files and wait for upload progress to finish.
Open the uploaded files to confirm they belong to the correct visit.
New uploads are private. Share with client is a separate choice; uploading a scan for staff review does not itself share it with the client.
Return to Ultrasound → Info to select the physician, choose Notify User After Doctor Signs, save, and use Send to Physician. See Ultrasound: Images, Findings, and Doc Alert.
Save records your edits.
Send to Physician starts the ultrasound's Doc Alert.
A reviewer's sign-off completes the required document review.
Completing the visit follows your center's remaining visit requirements.
A successful send is not a physician signature. Check the Doc Alert state in Ultrasound Info and use Approvals → Submitted by me to track work you sent.
A note lock protects a specific visit note. It can be set manually or automatically on save according to your center's settings. It is separate from document sign-off.
An ultrasound sent for Doc Alert can also be protected from edits. Do not reset it just to work around an unavailable button. Use the returned-correction path when offered, or ask an administrator to review the current state.
Signed chart documents have their own correction history and may offer Addendums. That panel is not the same thing as unlocking a visit note or resetting a Doc Alert. See Note Locks, Doc Alert Recovery, and Chart Addendums.
Save before switching sections or documents. If CoolFocus warns about unsaved changes, stay on the current item and save before continuing unless you intend to discard those edits.
Each visit shows up as its own entry on the client's timeline and, if linked to a case, on that case's timeline too.
• The entry is labeled "Visit" with a stethoscope icon. The summary can show primary visit reason, visit status, center, and consultant when available.
• The entry links back to the visit for full detail.
• Deleted visits, and visits without a recorded visit date, are left off the timeline.
• Seeing this entry requires permission to view visit activity. A user or group without that permission will not see these entries even if they can open the client or case. See User Groups: What Staff Can Open and Change.
When a visit records that an STI test was performed, that test appears as its own timeline entry on the client (and linked case).
• The entry shows a short summary of results by test (for example, "Chlamydia: Negative, Gonorrhea: Positive"), or "STI test performed" if no individual results were recorded.
• It links back to the visit for full detail. Notes and treatment are not shown on the timeline itself — only the result summary.
• Deleted visits, and STI tests without a visit date, are left off the timeline.
• Viewing requires permission for STI test activity. See User Groups: What Staff Can Open and Change.
When a visit records that a pregnancy test was performed, that test also appears as its own timeline entry on the client (and linked case).
• The entry is labeled "Pregnancy Test" and can summarize the result, whether results were confirmed, and whether the test was offsite. If none of that was recorded, it reads "Pregnancy test."
• It links back to the visit for full detail.
• Deleted visits, and pregnancy tests without a visit date, are left off the timeline.
• This is separate from Previous Pregnancies history on the client record. A Previous Pregnancies "Pregnancy Test Date" milestone comes from recorded pregnancy history and only appears on the client's own timeline. A visit pregnancy-test entry reflects a test performed during a visit and can appear on both the client and a linked case timeline (like Vitals and STI Test).
• Viewing requires permission for pregnancy test activity. See User Groups: What Staff Can Open and Change.
