> ## Documentation Index > Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt > Use this file to discover all available pages before exploring further. # Doctor Consultation > How to conduct a doctor consultation at the Diagnostic and Scan Centre - recording clinical findings, ordering investigations, and documenting the patient encounter. When the centre's own physician or radiologist meets a patient directly (rather than just performing a scan ordered by an external doctor), the visit is recorded as a Patient Encounter. This is the core consultation record. **Who does this:** Healthcare Practitioner (Physician, Radiologist) **Requires:** A booked Consultation appointment. Vital signs should be recorded before the consultation begins. *** ## 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**. | Field | What to Record | | ---------------- | ----------------------------------------------- | | Patient | Select the patient | | Temperature | Body temperature in °C or °F | | Pulse Rate | Beats per minute | | Respiratory Rate | Breaths per minute | | Blood Pressure | Systolic / Diastolic (e.g., 120/80) | | SpO2 | Oxygen saturation percentage | | Weight | Weight in kg | | Height | Height in cm | | BMI | Calculated automatically from weight and height | 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. Patient Encounter form showing patient details, presenting complaint, examination findings, and investigation order sections *** ## 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: | Procedure | What It Covers | | ---------- | -------------------------------------------------------------- | | CT Scan | Detailed cross-section imaging of chest, abdomen, brain, bones | | MRI Scan | Soft tissue, brain, spinal cord, joints | | Ultrasound | Abdomen, pelvis, thyroid, pregnancy | | X-Ray | Chest, bones | 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. Submitted Patient Encounter showing all recorded findings, diagnosis, and investigation orders *** ## After the Consultation | Next Step | Action | | --------------------------- | -------------------------------------------- | | Patient needs a scan | Receptionist books a Scanning appointment | | Patient needs a blood test | Receptionist books a Lab Test appointment | | Patient needs medicine | Pharmacist dispenses at the pharmacy counter | | Consultation to be invoiced | Receptionist creates a Patient Invoice | *** ## Patient Encounter Field Reference | Field | Purpose | | ------------------------------- | ------------------------------------------------ | | Patient | The person being seen | | Appointment | Links to the consultation appointment | | Healthcare Practitioner | The doctor who conducted the consultation | | Date | Date of the consultation | | Symptoms | Presenting complaints | | Diagnosis | Provisional or confirmed diagnosis with ICD code | | Clinical Notes | Free-text examination findings | | Lab Tests Prescription | Ordered blood tests | | Clinical Procedure Prescription | Ordered scans | | Drug Prescription | Ordered medicines | | Status | Draft / Submitted | *** ## 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.