Before You Start
- A patient appointment should already exist for the visit.
- You must have the Physician role to create and submit Patient Encounters.
- Nurses can record Vital Signs without the Physician role.
Recording Vital Signs
Before the doctor sees the patient, the nurse records their vital signs. These become part of the patient’s permanent history.- Go to Healthcare workspace → Consultation card → Vital Signs → New
- Select the Patient
- Link to the Appointment (optional but recommended)
- Record the readings:
- Save
Conducting a Consultation: Patient Encounter
A Patient Encounter is the official record of what happened during a consultation. Every clinical decision - symptoms, diagnosis, prescriptions, therapy orders - is recorded here.Step 1: Open a New Patient Encounter
Go to Healthcare workspace → Consultation card → Patient Encounter → New. Or open the Patient Appointment and use the button to create an encounter directly from it (the patient and appointment are pre-filled).
Step 2: Link Patient and Appointment
Step 3: Record Symptoms
In the Symptoms table, add each symptom the patient reports. Select from the predefined list or type a new one. Examples for rehabilitation patients:- Right knee pain on walking
- Reduced range of motion - left shoulder
- Loss of grip strength - right hand
- Difficulty climbing stairs
- Balance problems when standing
Step 4: Record Diagnosis
In the Diagnosis table, add the clinical diagnosis. Select from the standard diagnosis list (which can include ICD codes if configured) or type freely. Examples:- Post-surgical knee rehabilitation
- Stroke rehabilitation - right hemiplegia
- Lumbar disc herniation
- Traumatic brain injury - cognitive rehabilitation
- Rotator cuff tear rehabilitation
Step 5: Prescribe Therapies
In the Therapies table, specify which therapy types are needed and how many sessions:
When saved, the system generates a Therapy Plan (or adds to an existing one) based on these prescriptions.
Step 6: Drug Prescription (If Needed)
In the Drug Prescription table, add any medications:Step 7: Lab Test Orders (If Needed)
In the Lab Prescription table, add any lab tests ordered:Step 8: Clinical Procedure Orders (If Needed)
In the Procedure Prescription table, prescribe any clinical procedures (injections, dressings, etc.).Step 9: Notes
Use the Encounter Comment field to write any additional clinical notes or instructions not covered by the structured fields.Step 10: Save and Submit
Click Save to save as a draft. Click Submit to finalize. When submitted, the encounter becomes part of the permanent patient record and automatically creates Service Requests for ordered therapies and labs.Field Guide: Patient Encounter
Clinical Notes
Clinical Notes are informal observations that do not fit into a formal encounter. They are used for:- Phone call notes (“Patient called to report pain, advised to rest and ice”)
- Inter-shift observations by nurses
- Observations between formal appointments
Adding a Clinical Note
- Go to Healthcare workspace → any patient record or Consultation card → Clinical Note → New
- Select the patient
- Choose the Clinical Note Type (e.g., Observation, Phone Note, Nursing Note)
- Write the note in the Note field
- Select the practitioner or user writing the note
- Save
Treatment Plan Templates
For common rehabilitation scenarios, your Admin can set up Treatment Plan Templates. A template pre-fills the therapy types, session counts, and even practitioner assignments for a standard care pathway. For example, a “Post-Knee Replacement Protocol” template might include:- 12 sessions of Physiotherapy
- 6 sessions of Hydrotherapy
- 4 sessions of Occupational Therapy
Automations in Clinical Operations
Medical Record Auto-Sync
Every time a Patient Encounter is submitted, it automatically appears in the Patient History page. The doctor or therapist at the next visit sees the previous encounter notes without having to search.Service Request Auto-Creation
When “Submit Orders on Save” is turned on in the encounter, saving the encounter automatically creates:- Service Requests for each prescribed therapy
- Lab test orders for each prescribed lab test
Troubleshooting
I cannot submit the Patient Encounter Check that all required fields are filled - at minimum, the Patient and Practitioner must be selected. If a diagnosis table has an incomplete row, it will block submission. The therapy plan was not created after I submitted the encounter Check that at least one row exists in the Therapies table with a Therapy Type and session count. Also check that “Submit Orders on Save” is on if you expected automatic order creation. I cannot find the patient encounter from yesterday Search in the Patient History page (shortcut in the workspace) by patient name. All submitted encounters appear there.Best Practices
- Always record symptoms before diagnosis - it creates a clinical narrative that helps future practitioners understand the patient’s history
- Link every encounter to its appointment - this ensures billing is tracked correctly against the visit
- Use Treatment Plan Templates for common rehabilitation programs - it saves time and ensures consistency
- Submit the encounter on the same day as the visit - drafts are easy to forget and unbilled encounters are a revenue loss
- Add clinical notes for any patient communication between visits - a complete record protects the center in case of disputes
Related Features
- Appointments: The appointment that this encounter links to
- Therapy Plans and Sessions: The therapy plan created from this encounter
- Laboratory: The lab tests ordered in this encounter
- Billing and Finance: How encounters are invoiced