Consultations & Clinical Notes

A triage nurse opens the patient’s encounter record and captures temperature, blood pressure, pulse rate, respiratory rate, weight, height, and BMI. The values are stored against the visit and displayed at the top of the clinician’s consultation screen, so the doctor sees the current vitals without asking for a verbal handover. Values outside normal reference ranges are highlighted automatically.

The clinician opens the encounter and records the presenting complaint in a structured free-text field, followed by examination findings. The notes editor supports structured sections — history of presenting complaint, systems review, examination findings — so the record is consistent across clinicians and readable at a future visit. Auto-save prevents any loss of a partially completed note.

Diagnoses are selected from the ICD-10 code list using a searchable picker: type the condition name or the code and the matching entries appear. Multiple diagnoses can be recorded on a single encounter. Coding diagnoses at the point of care means the facility’s disease surveillance data is available without a separate coding exercise after the patient has left.

The treatment plan documents the clinical decisions made: medications prescribed (linked to the prescriptions module), procedures ordered, lifestyle advice given, and follow-up instructions. The plan is stored on the visit record so a different clinician seeing the patient next time can read exactly what was decided and why, without the patient needing to remember.

When a patient needs to be referred to a specialist or to a higher-level facility, the clinician creates a referral record within the consultation. The referral captures the receiving provider, the reason, and the urgency level, and generates a printable referral letter that can be given to the patient or sent directly if the receiving facility is also on the platform.

Every signed-off consultation appears in the patient’s visit history, accessible from the consultation screen with a single click. The history lists visits in reverse chronological order with the date, attending clinician, and primary diagnosis. Expanding any entry shows the full encounter record including vitals, notes, prescriptions, and lab orders, giving the current clinician the full picture of the patient’s care.

When the clinician is satisfied with the record, they sign off the consultation. The record is locked against further editing, and the timestamp and clinician’s name are recorded permanently. This creates a legally and clinically sound audit trail and prevents retrospective alteration of clinical decisions.