Before the Consultation: Vital Signs
A nursing staff member records the patient’s vital signs before the doctor sees them. Go to Consultation in the workspace and click Vital Signs, then click New.
Click Save. The vital signs will appear in the Patient History timeline and will be visible to the doctor in the Patient Encounter.
Opening a Patient Encounter
Go to Consultation and click Patient Encounter, then click New. Alternatively, open the patient’s appointment record and click Create Patient Encounter from the action buttons. This prefills the patient details automatically.
Recording the Consultation
Patient Complaint
In the Symptoms section, record what the patient is presenting with. Type the symptom (for example, “Headache”, “Abdominal pain”) and select from the autocomplete list, or type a new entry.Examination Findings
In the Clinical Notes or In Patient Notes section, record the examination findings in free text. For example: “Patient presents with 3-week history of right knee pain. Tenderness on medial joint line. Mild swelling noted. MRI recommended to rule out meniscal tear.”Diagnosis
In the Diagnosis section, enter the provisional or confirmed diagnosis. This links to the standard ICD code list.Ordering Investigations
If the doctor decides the patient needs a scan or blood test, the order is placed from within the Patient Encounter.Ordering a Scan (Clinical Procedure)
Click Get Prescribed Clinical Procedures or navigate to the Clinical Procedure Prescription section. Add the required scan:
After the encounter is saved, the receptionist books a Scanning appointment and the scan team creates the Clinical Procedure record.
Ordering a Blood Test (Lab Test)
Navigate to the Lab Tests Prescription section and add the required test (H1B1, Hemoglobin, or any other available template). After saving, the receptionist books a Lab Test appointment.Ordering Medicine (Medication Request)
If a prescription is needed, navigate to the Drug Prescription section and add each medicine with its dosage and frequency.Submitting the Encounter
Click Submit when the consultation is complete. A submitted encounter is locked and becomes part of the patient’s permanent medical record. It will appear in the Patient History timeline.
After the Consultation
Patient Encounter Field Reference
Best Practices
- Record vital signs before every consultation, not just when the patient appears unwell. They provide a baseline for comparison on future visits.
- Attach the referral letter (if the patient has one) to the Patient Encounter so the radiologist reviewing the scan can see the clinical context.
- Submit the encounter before the patient leaves the consultation room. A draft encounter does not appear in the patient’s history.
- When ordering a scan with contrast (such as CT with contrast or MRI with gadolinium), note this in the Clinical Procedure Prescription so the nursing team can screen for allergies and prepare the contrast kit.