Consultation, diagnoses and orders

Clinical care

Consultation, diagnoses and orders

Write the clinical note, add ICD diagnoses, order tests and imaging, and finalise.

Who uses it: Doctors and clinical officers
Where to find it: OPD Consultation → Open → Consultation

1Write the note

1
Start
Open the patient from “OPD Consultation” and click “Start consultation”. The triage vitals are shown at the top.
2
History and examination
Record the presenting complaint, history and examination findings.
3
Diagnoses
Search and add diagnoses from the diagnosis list (ICD coded). Use “Remove diagnosis” to correct mistakes.
4
Save as you go
Click “SAVE DRAFT” at any time. A draft can still be edited.

2Order tests, imaging and procedures

1
Laboratory
Add the tests you need and set the priority: Routine, Urgent or STAT. Orders appear at once in the lab’s “To collect” list.
2
Imaging
Use “Request imaging”, choose the exam, add the clinical indication and priority.
3
Prescribe
Add medicines from the pharmacy stock (see Prescribing).

3Finish the consultation

1
Follow-up
Set a follow-up date and notes if needed.
2
Finalise
Click “FINALIZE CONSULTATION”. The note is then locked, as clinical records must be.
3
Corrections later
To add information after finalising use “Add addendum”. The original note stays visible.

Need help with this? Our team can show you on a call.