> ## 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.
# Clinical Operations
> How doctors and therapists conduct consultations, record diagnoses, prescribe treatments, and document clinical notes during patient visits.
Clinical operations cover everything that happens during a patient visit at the hands of a doctor or therapist. This includes the consultation record, symptom and diagnosis documentation, prescriptions, and clinical notes. Every decision made in the clinic flows from these records into the rest of the system.
***
## 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.
1. Go to Healthcare workspace → Consultation card → **Vital Signs** → New
2. Select the **Patient**
3. Link to the **Appointment** (optional but recommended)
4. Record the readings:
| Vital Sign | What to Record |
| ------------------------ | ----------------------------------------------- |
| Temperature | Body temperature (°C) |
| Pulse | Heart rate (beats per minute) |
| Respiratory Rate | Breaths per minute |
| Blood Pressure Systolic | Upper blood pressure reading |
| Blood Pressure Diastolic | Lower blood pressure reading |
| Height | In cm or meters |
| Weight | In kg |
| BMI | Calculated automatically from height and weight |
| Vital Signs Note | Any observation about the readings |
| Nutrition Note | Any dietary or nutritional observation |
5. Save
The vital signs are now linked to the patient and appear in their history.
***
## 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
| Field | What to Enter |
| ------------------ | ---------------------------------------- |
| Patient | Select the patient |
| Appointment | Select the appointment for this visit |
| Practitioner | The doctor conducting the consultation |
| Encounter Date | Today's date (auto-filled) |
| Medical Department | The department conducting this encounter |
### 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:
| Field | What to Enter |
| ------------ | --------------------------------------------------------- |
| Therapy Type | Physiotherapy, Occupational Therapy, Speech Therapy, etc. |
| Sessions | Number of sessions prescribed |
| Practitioner | The therapist who will conduct the 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:
| Field | What to Enter |
| --------------------- | ------------------------------------------------------ |
| Medication | The drug name |
| Dosage | Dose amount (e.g., 500mg) |
| Dosage Form | Tablet, Syrup, Injection, etc. |
| Prescription Duration | How many days (e.g., 7 days, 1 month) |
| Note | Instructions for the patient (e.g., "Take after food") |
### Step 7: Lab Test Orders (If Needed)
In the **Lab Prescription** table, add any lab tests ordered:
| Field | What to Enter |
| ----------------- | ------------------------------------------------------ |
| Lab Test Template | Select the test type (e.g., CBC, Lipid Profile, X-Ray) |
| Practitioner | The requesting doctor |
| Date | When the test should be done |
### 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
| Field | What It Contains |
| ---------------------- | -------------------------------------------------- |
| Patient | The patient seen in this encounter |
| Appointment | The linked appointment |
| Practitioner | The doctor or therapist conducting the encounter |
| Encounter Date | The date of the visit |
| Status | Draft, Completed, etc. |
| Symptoms | List of symptoms reported by the patient |
| Diagnosis | Clinical diagnoses made in this encounter |
| Drug Prescription | Medications prescribed |
| Lab Prescription | Lab tests ordered |
| Procedure Prescription | Clinical procedures ordered |
| Therapies | Therapy types and sessions prescribed |
| Therapy Plan | The linked therapy plan (auto-created or existing) |
| Encounter Comment | Free-text clinical notes |
| Invoiced | Whether this encounter has been billed |
***
## 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
1. Go to Healthcare workspace → any patient record or Consultation card → **Clinical Note** → New
2. Select the patient
3. Choose the **Clinical Note Type** (e.g., Observation, Phone Note, Nursing Note)
4. Write the note in the **Note** field
5. Select the practitioner or user writing the note
6. Save
Clinical notes appear in the patient's history automatically.
***
## 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
The doctor selects the template in the Patient Encounter and the system applies all the prescriptions at once - saving significant time for common cases.
***
## 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
This removes the manual step of creating orders separately.
***
## 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](/health-wellness/rehabilitation-center/appointments): The appointment that this encounter links to
* [Therapy Plans and Sessions](/health-wellness/rehabilitation-center/therapy-plans-sessions): The therapy plan created from this encounter
* [Laboratory](/health-wellness/rehabilitation-center/laboratory): The lab tests ordered in this encounter
* [Billing and Finance](/health-wellness/rehabilitation-center/billing-finance): How encounters are invoiced