Follow-Up System

Overview

DataMed’s follow-up system tracks patient engagement across the 18-month capita cycle, automatically identifies patients without recent contact, and manages transitions between admission states (ACTIVO, SUSPENDIDO, TERMINADO).

The follow-up system operates on a 15-day alert threshold - patients without contact in 15 days appear in the dashboard alert list.

Follow-Up Manager

The Follow-Up Manager (followups_manager) provides a centralized view of all patients with their admission history and state management controls.

Accessing the Follow-Up Manager

Navigate to Follow-Ups

From the main menu, select Patients → Follow-Up Manager or Gestión de Seguimientos

View Patient List

The manager displays all patients (regardless of state) with:

Patient demographic information
All admission cycles (Ingresos) with states
Current capita month for active admissions
State change actions

Search and Filter

Use the search bar to filter by:

Patient name (nombre)
Patient surname (apellido)
Document number (documento)

Data Loading

# From views.py:136-164
def followups_manager(request):
    query = request.GET.get("query_search")
    
    # Optimized query with prefetch_related to avoid N+1 queries
    patients_list = Patient.objects.all()\
        .prefetch_related('ingresos')\
        .order_by('nombre')
    
    if query:
        patients_list = patients_list.filter(
            Q(documento__icontains=query) | 
            Q(nombre__icontains=query) | 
            Q(apellido__icontains=query)
        )
    
    # Pagination: 10 patients per page
    paginator = Paginator(patients_list, 10)
    page_number = request.GET.get('page')
    page_obj = paginator.get_page(page_number)

Performance Optimization

The view uses prefetch_related('ingresos') to load all admission cycles in a single query, preventing the N+1 query problem when displaying multiple patients with their admission histories.

Admission States

Each patient admission (Ingreso) has one of three states:

ACTIVO

Patient actively receiving treatment

Conta months progress automatically
Clinical records can be registered
Appears in active patient lists

SUSPENDIDO

Treatment temporarily paused

Common reasons: equipment issues, patient travel, medical contraindications
Capita clock continues running
No clinical activity expected

TERMINADO

Admission cycle completed

Requires end date and reason
Capita cycle closed
Patient can start new cycle if needed

State Model

# From models.py:153-184
class Ingreso(models.Model):
    ESTADO_CHOICES = [
        ('ACTIVO', 'Activo'),
        ('SUSPENDIDO', 'Suspendido'),
        ('TERMINADO', 'Terminado')
    ]
    
    paciente = models.ForeignKey(
        'Patient', 
        on_delete=models.CASCADE, 
        related_name='ingresos'
    )
    fecha_inicio = models.DateField()
    fecha_fin = models.DateField(null=True, blank=True)
    estado = models.CharField(
        max_length=20, 
        choices=ESTADO_CHOICES, 
        default='ACTIVO'
    )
    motivo = models.TextField(blank=True, null=True)

Changing Admission States

Marking as TERMINADO

Closing an admission cycle requires additional information:

Access State Change

In the Follow-Up Manager, locate the patient’s active admission and click the Terminate or Terminar button

Enter Closure Details

A modal form appears requesting:

fecha_terminacion: End date of the cycle
motivo_estado: Reason for termination

Common reasons:

Completed 18-month cycle
Patient deceased
Patient transferred to another facility
Patient non-compliant
Health plan changed

Confirm Termination

The system processes the state change:

# From views.py:169-188
def change_status_entry(request, entry_id, new_status):
    ingreso = get_object_or_404(Ingreso, id=entry_id)
    
    if request.method == 'POST' and new_status == 'TERMINADO':
        # Capture required closure data
        ingreso.fecha_fin = request.POST.get('fecha_terminacion')
        ingreso.motivo = request.POST.get('motivo_estado')
        ingreso.estado = 'TERMINADO'
        ingreso.save()
        
        messages.success(
            request, 
            f"Ciclo de {ingreso.paciente.nombre} finalizado y archivado ✅"
        )
    
    return redirect('patients_follow')

Once an admission is marked TERMINADO, all associated clinical records are preserved but no longer visible in the active clinical dashboard. This ensures clean separation between cycles.

Creating a New Admission Cycle

After completing an 18-month cycle, patients can start a new cycle:

Verify Previous Cycle Closure

Before creating a new cycle, ensure the previous admission is TERMINADO:

# From views.py:209-213
tiene_ciclo_abierto = patient.ingresos.filter(
    estado__in=['ACTIVO', 'SUSPENDIDO']
).exists()

if tiene_ciclo_abierto:
    messages.error(
        request, 
        "No se puede iniciar nuevo ciclo: El paciente tiene un proceso pendiente."
    )

Initiate New Cycle

From the Follow-Up Manager, click New Cycle or Nuevo Ciclo for the patient

Set Start Date

Enter the new cycle start date in the modal form

Create Admission

The system creates a fresh ACTIVO admission:

# From views.py:215-222
Ingreso.objects.create(
    paciente=patient,
    fecha_inicio=fecha,
    estado='ACTIVO'
)
messages.success(
    request, 
    f"¡Nuevo ciclo iniciado para {patient.nombre}!"
)

Why Prevent Overlapping Cycles?

The system prevents creating a new cycle while an existing cycle is ACTIVO or SUSPENDIDO because:

Clinical Clarity: Staff should only work with one active cycle at a time
Data Integrity: All clinical records must unambiguously belong to a single cycle
Financial Accounting: Capita payments are tied to specific admission periods
Compliance: Healthcare regulations require clear episode boundaries

Dashboard Alerts

The main dashboard automatically identifies patients needing follow-up attention:

15-Day Alert Logic

# From dashboard/views.py:17-36
hoy = timezone.now().date()
limite = hoy - timezone.timedelta(days=15)

# Find patients without recent follow-up
pacientes_sin_seguimiento = Patient.objects.filter(
    ingresos__estado='ACTIVO'
).annotate(
    fecha_del_ingreso=Max('ingresos__fecha_inicio'),
    ultima_atencion=Max('ingresos__seguimientos__fecha_atencion')
).filter(
    Q(ultima_atencion__lt=limite) |  # Last visit > 15 days ago
    Q(ultima_atencion__isnull=True, fecha_del_ingreso__lt=limite)  # Never visited and admitted > 15 days ago
).distinct().order_by('ultima_atencion', 'fecha_del_ingreso')

total_sin_seguimiento = pacientes_sin_seguimiento.count()

Alert Criteria
Alert Display
Follow-Up Model

A patient appears in the alert list if they have an ACTIVO admission AND:Scenario 1: No Follow-Up Recorded

Admission date is more than 15 days ago
No Seguimiento records exist for this cycle

Scenario 2: Overdue Follow-Up

Last fecha_atencion is more than 15 days ago
Patient needs re-engagement

# From exams/models.py:356-387
class Seguimiento(models.Model):
    ingreso = models.ForeignKey(
        Ingreso,
        on_delete=models.CASCADE,
        related_name='seguimientos'
    )
    registrado_por = models.ForeignKey(
        settings.AUTH_USER_MODEL,
        on_delete=models.SET_NULL,
        null=True,
        blank=True,
        related_name='seguimientos_registrados'
    )
    fecha_atencion = models.DateField()
    tipo_servicio = models.CharField(max_length=100)
    created_at = models.DateTimeField(auto_now_add=True)
    
    class Meta:
        ordering = ['-fecha_atencion']

The Seguimiento model is distinct from SeguimientoAdaptacion.

Seguimiento: General follow-up appointments (face-to-face, phone calls)
SeguimientoAdaptacion: Adaptation notes associated with technical monitoring

Follow-Up Workflows

Recording a Follow-Up Contact

While DataMed doesn’t currently have a dedicated follow-up registration form, follow-ups are typically recorded through:

Clinical Record Entry

When registering any clinical exam (monitoring, psychology, etc.), a follow-up contact is implicitly recorded via the exam timestamp

Adaptation Notes

Use the Contact Notes tab in the monitoring form to document phone or in-person follow-ups:

# SeguimientoAdaptacion model from exams/models.py:390-418
class SeguimientoAdaptacion(models.Model):
    ingreso = models.ForeignKey(Ingreso, on_delete=models.CASCADE)
    created_at = models.DateTimeField(auto_now_add=True)
    observaciones = models.TextField(
        verbose_name="Observaciones de Seguimiento"
    )

Manual Seguimiento Entry

Create a Seguimiento record directly (requires custom admin or form):

Set fecha_atencion to contact date
Specify tipo_servicio (e.g., “Llamada telefónica”, “Visita domiciliaria”)

Recommended Follow-Up Schedule

Follow-Up Frequency by Capita Month

Months 1-3: Intensive Phase

Week 2: Initial adaptation check (phone)
Week 4: First monthly review (in-person)
Month 2: Adjustment visit (in-person)
Month 3: Quarterly assessment (in-person)

Months 4-18: Maintenance Phase

Every 3 months: Quarterly review (in-person or phone)
As needed: Troubleshooting visits

Month 18: Closure Phase

Final assessment (in-person)
Equipment return (if applicable)
Cycle closure decision

Capita Distribution Tracking

The dashboard includes a visual distribution of active patients by capita month:

# From dashboard/views.py:41-56
ingresos_activos = Ingreso.objects.filter(estado='ACTIVO')

# Group by capita month using property
conteos = {}
for ing in ingresos_activos:
    mes = ing.mes_capita
    if mes:
        conteos[mes] = conteos.get(mes, 0) + 1

# Sort for chart display
meses_ordenados = sorted(conteos.keys())
labels_grafica = [f"Capita {m}" for m in meses_ordenados]
datos_grafica = [conteos[m] for m in meses_ordenados]

Chart Purpose
Interpreting Patterns

The capita distribution chart helps identify:

Cohort Size: How many patients at each stage
Bottlenecks: Unusual concentrations at specific months
Capacity Planning: Upcoming workload predictions
Program Health: Steady flow vs. clustering

Patient Engagement Strategies

Proactive Outreach

Use the dashboard alert list daily to:

Call patients before they reach 15 days
Schedule appointments proactively
Address barriers to engagement

Automated Reminders

Future enhancement opportunity:

SMS reminders at 10 days
Email notifications
WhatsApp integration

Dropout Prevention

Flag patients at risk:

Multiple missed appointments
Low CPAP adherence
Consistently > 30 days between contacts

State Transitions

Use SUSPENDIDO appropriately:

Patient traveling (temporary)
Equipment repair needed
Medical contraindication

Prevents premature TERMINADO status

Pagination and Performance

Both the Follow-Up Manager and Dashboard alerts use pagination:

# Standard pagination pattern
paginator = Paginator(patients_list, 10)
page_number = request.GET.get('page')
page_obj = paginator.get_page(page_number)

Why 10 Patients Per Page?

The system uses 10-patient pagination to:

Optimize page load times (especially on Render.com hosting)
Reduce memory usage with large patient databases
Improve mobile responsiveness
Maintain consistent UI performance

Best Practices

Check dashboard alerts daily

Make the dashboard your first stop each day to identify patients needing immediate attention. The 15-day threshold ensures timely intervention.

Document all patient contacts

Record every interaction, even brief phone calls, to:

Reset the 15-day alert timer
Maintain audit trail
Track engagement patterns

Use SUSPENDIDO appropriately

When patients need a temporary treatment pause:

Mark admission as SUSPENDIDO (not TERMINADO)
Document reason in motivo field
Set expected resumption date in notes
Monitor for return to ACTIVO status

Close cycles properly

Always provide end date and reason when marking TERMINADO:

Ensures accurate capita tracking
Supports financial reconciliation
Enables outcome analysis

Plan for Month 18 transitions

When patients approach Month 18:

Schedule closure assessment
Determine if new cycle is medically indicated
Coordinate equipment return/reassignment
Complete final documentation

Next Steps

Dashboard Overview

Explore all dashboard features and statistics

Patient Management

Learn about patient lifecycle and capita cycles

Documentation Index

​Overview

​Follow-Up Manager

​Accessing the Follow-Up Manager

​Data Loading

​Admission States

ACTIVO

SUSPENDIDO

TERMINADO

​State Model

​Changing Admission States

​Marking as TERMINADO

​Creating a New Admission Cycle

​Dashboard Alerts

​15-Day Alert Logic

​Follow-Up Workflows

​Recording a Follow-Up Contact

​Recommended Follow-Up Schedule

​Capita Distribution Tracking

​Patient Engagement Strategies

Proactive Outreach

Automated Reminders

Dropout Prevention

State Transitions

​Pagination and Performance

​Best Practices

​Next Steps

Dashboard Overview

Patient Management

Overview

Follow-Up Manager

Accessing the Follow-Up Manager

Data Loading

Admission States

State Model

Changing Admission States

Marking as TERMINADO

Creating a New Admission Cycle

Dashboard Alerts

15-Day Alert Logic

Follow-Up Workflows

Recording a Follow-Up Contact

Recommended Follow-Up Schedule

Capita Distribution Tracking

Patient Engagement Strategies

Pagination and Performance

Best Practices

Next Steps