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Record a consultation and prescription

Take vitals, write the diagnosis and medicines, complete the visit and print the prescription.

On this page

Open a visit from the queue with Open (or Start). The visit page shows the patient's number, phone and blood group, and any allergies or long-term conditions in red at the top.

Write the clinical record

  1. Check the Doctor and the Problem / complaint.
  2. If the patient is still waiting, click Start consultation. This saves what you have typed and moves the visit to With the doctor.
  3. Under Vitals enter BP top (mmHg), BP bottom (mmHg), Pulse (/min), Temperature (°C), SpO2 (%), Weight (kg) and Height (cm). BMI is calculated for you once weight and height are entered.
  4. Write the Examination and the Diagnosis.
  5. Under Medicines, click Add medicine and fill in Medicine, Dose, How often, Days and Instructions (for example "after food"). Use Remove to delete a line.
  6. Add Tests advised, Follow-up on (a date, today or later) and Advice.
  7. Click Save whenever you want to keep your work.

Complete the visit

Click Complete visit. A Diagnosis is required. Completing saves the record, locks it so it can no longer be changed, and completes any linked appointment. You can then add charges and settle the bill (Charges and billing). Cancel visit ends a visit without completing it.

Once the visit is completed, a Prescription appears at the bottom of the page. It shows the clinic name, doctor, date and token, the patient, the diagnosis, the numbered medicines, tests, advice and follow-up date. Click Print prescription to print only that section.

Good to know

  • Medicines are typed as free text. Prescribing does not take anything out of stock; to sell medicines to the patient, add them as catalogue items on the bill.
  • If two people edit the same visit, the second save is refused with a message to reload. Reload and re-enter your change.
  • Earlier visits of the same patient are listed on the right so you can open and review them.
  • Needs the Clinic Edit permission to write; View is read-only.
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