> ## 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.
# Consultations
> How doctors record a patient visit - symptoms, examination, diagnosis, prescriptions, lab orders, procedure orders, and referrals - all in a single consultation record.
The consultation record (called a Patient Encounter) is the most important document in the clinic system. It is the doctor's complete record of what happened during a patient visit: what the patient complained about, what the doctor found, what diagnosis was given, what medications were prescribed, and what tests or procedures were ordered.
Every prescription, lab order, and procedure order in the system traces back to a consultation record.
***
## Before You Start
* The patient must be registered.
* An appointment should exist (though consultations can be created without one).
* You need the **Healthcare Practitioner** role.
***
## Starting a Consultation
The quickest way to start a consultation is from the appointment:
1. Open the patient's **Patient Appointment** record
2. Click **Create Patient Encounter** (button at the top of the form)
Alternatively, create a new encounter directly:
1. Go to Healthcare workspace → Consultation card → **Patient Encounter** → New
The encounter form pre-fills the patient, practitioner, and date automatically.
***
## Recording Symptoms
In the **Symptoms** tab (or section), add what the patient has come in for:
1. Click in the Symptoms field and type the complaint
2. Select from existing complaint codes, or type a new one
3. Add as many symptoms as needed (fever, cough, headache, etc.)
This is also where you record the **Review Details** (physical examination findings, patient's own description of their problem).
***
## Recording the Diagnosis
In the **Diagnosis** section:
1. Click in the Diagnosis field
2. Type the diagnosis name and select from the list
3. Add multiple diagnoses if needed
Standard diagnosis codes (ICD-10, SNOMED, or your clinic's own codes) can be set up in the Diagnosis master. Medical codes from international code systems can also be added in the Medical Codes table.
***
## Writing Prescriptions (Drug Prescription)
In the **Drug Prescription** section, add each medication the patient needs:
| Field | What to Enter |
| ---------------- | ------------------------------------------------------ |
| Drug Code | Search for the medication from the Items list |
| Dosage | How much per dose (e.g., 500mg, 1 tablet) |
| Dosage Form | How it is taken (tablet, syrup, injection, etc.) |
| Strength | Concentration (e.g., 500mg) |
| Period | How long to take it (5 days, 1 month, etc.) |
| Dosage Frequency | How often (once daily, twice daily, after meals, etc.) |
Prescription entries can be printed directly from the consultation record (Print button at the top). They also appear in the patient's portal so the patient can view their own prescription online.
***
## Ordering Lab Tests
In the **Lab Tests** section, order the investigations needed:
1. Click in the Lab Test Template field
2. Select the test to order (Blood Sugar, Complete Blood Count, Urine Routine, Lipid Profile, etc.)
3. Add as many tests as needed
When you save or submit the encounter (with "Submit Orders on Save" ticked in Healthcare Settings), the system automatically creates Lab Test records for each ordered test. The lab team then sees these tests in their queue.
***
## Ordering Clinical Procedures
In the **Clinical Procedures** section, order any procedure to be performed:
1. Select the Clinical Procedure Template (e.g., ECG, Dressing, Injection, Nebulisation)
2. Add the service unit where it will be performed (optional)
A Clinical Procedure record is created in the system, which the nurse or doctor performing the procedure will then open and complete. See [Clinical Procedures](/health-wellness/general-clinic/clinical-procedures) for the complete process.
***
## Ordering Therapies (Physiotherapy Referrals)
In the **Therapies** section, refer the patient for physiotherapy or other therapies:
1. Select the therapy type
2. Link a Therapy Plan if one exists for the patient
3. Enter the number of sessions needed
***
## Applying a Treatment Plan Template
For common conditions, your clinic can have pre-built templates that fill in standard medications, lab orders, and procedures automatically.
1. Click the **Treatment Plan Template** button (at the top of the form)
2. Select the template for this condition
3. All standard items from the template fill in automatically
4. The doctor reviews and modifies as needed for this specific patient
***
## Ordering Inpatient Admission
If the patient needs to be admitted overnight:
1. In the consultation, select the **Inpatient Status** as "Admission Scheduled"
2. This signals to the admin team that an inpatient bed needs to be arranged
3. The admin team creates an Inpatient Record and assigns a bed
***
## Submitting the Consultation
When the consultation is complete:
1. Review all entries (symptoms, diagnosis, prescriptions, orders)
2. Click **Save** (which may also auto-create lab test and procedure records if enabled)
3. Click **Submit** to finalise the record
Once submitted, the consultation cannot be edited. If a correction is needed, use the **Amend** button to create a revised copy.
The appointment status changes to **Closed** automatically when the encounter is submitted.
***
## Adding Clinical Notes
Clinical notes are shorter, informal notes that can be added at any point - after a phone call with the patient, to record a follow-up observation, or to add context to the patient's record without creating a full encounter.
1. Go to Healthcare workspace → Nursing card → **Clinical Note** → New (or create from the patient record)
2. Select the patient
3. Choose the clinical note type (if your clinic has categories set up)
4. Write the note in the free text field
5. Save
Clinical notes appear in the patient's history timeline alongside formal encounters.
***
## Field Guide: Patient Encounter
| Field | What It Contains |
| ----------------------- | --------------------------------------------------------------------------- |
| Patient | The patient being seen |
| Healthcare Practitioner | The doctor recording the encounter |
| Encounter Date | Date of the visit |
| Appointment | Linked appointment (auto-filled if started from appointment) |
| Status | Draft (in progress) or Submitted (finalised) |
| Symptoms | Table of complaints (linked to Complaint master) |
| Diagnosis | Table of diagnoses (linked to Diagnosis master) |
| Drug Prescription | Table of medications prescribed |
| Lab Tests | Table of lab tests ordered |
| Clinical Procedures | Table of procedures ordered |
| Therapies | Table of therapy referrals |
| Review Details | Doctor's examination notes and free text |
| Invoiced | Whether the consultation fee has been billed |
| Submit Orders on Save | If ticked, Lab Test and Procedure records are created automatically on save |
***
## Troubleshooting
**The lab orders did not create Lab Test records automatically**
Check that "Submit Orders on Save" is ticked in the encounter, and that it is also enabled in Healthcare Settings. If the encounter was submitted without this setting, create the lab tests manually from the Lab Test list.
**I cannot edit a submitted consultation**
Submitted records are locked. Use the Amend button to create a new version. The original is preserved and the amendment shows as a linked record.
**The patient's prescription is not showing in the portal**
The prescription only appears in the portal after the encounter is submitted. If it has been submitted and the patient still cannot see it, check that their portal account is active and that Patient Encounter appears in the Patient History Settings.
**The appointment did not close after submitting the encounter**
Open the appointment and change the status to Closed manually. The automatic closure only happens when the encounter is submitted with a linked appointment.
***
## Best Practices
* Submit the encounter before the patient leaves - incomplete draft encounters are not visible in the patient history
* Use Treatment Plan Templates for common conditions - this speeds up documentation and ensures consistent treatment
* Always record at least one diagnosis - consultations without a diagnosis are not useful for the Diagnosis Trends report and may cause billing issues
* Record symptoms in the complaint field even if they seem obvious - this feeds the Symptoms analytics chart and helps clinical pattern recognition
* Add Review Details as free text for examination findings that do not fit into structured fields
***
## Related Features
* [Appointments](/health-wellness/general-clinic/appointments): The appointment that leads to a consultation
* [Laboratory](/health-wellness/general-clinic/laboratory): Lab tests ordered from the consultation
* [Clinical Procedures](/health-wellness/general-clinic/clinical-procedures): Procedures ordered from the consultation
* [Billing and Finance](/health-wellness/general-clinic/billing-finance): The consultation generates the primary billing event
* [Patient Portal](/health-wellness/general-clinic/patient-portal): Patients view their prescriptions online