Consultations
A consultation is one visit by one patient to one doctor. Every visit produces a structured record: vitals, history, examination, diagnosis, plan, and prescription.
The consultation form
The form follows the SOAP convention:
- Subjective — chief complaint, history of present illness, past history, family and social history.
- Objective — vitals (temperature, BP, pulse, SpO₂, weight, height, BMI), general and systemic examination findings.
- Assessment — provisional and final diagnoses (free-text or ICD-10).
- Plan — investigations ordered, prescriptions, follow-up date, advice.
Every section is optional. A short OP visit might only fill complaint, diagnosis, and prescription; an admission consult might use every field.
Editing past consults
A signed consultation cannot be edited freely. The product enforces an
edit policy (see consultation-edit-policy in the source):
- Within 24 hours — the doctor who wrote the note can edit it. Every change is logged.
- After 24 hours — only an admin can amend the note, and the amendment is recorded as an addendum, never as an overwrite.
This is by design. Hospitals are audited; charts cannot be silently rewritten.
Prescriptions
The prescription tool autocompletes from the pharmacy formulary. Every prescribed item flows through to:
- The pharmacy counter (so it shows up before the patient arrives).
- The patient timeline (with dose, frequency, duration).
- The print-ready prescription PDF.
For controlled substances, the system enforces the standard schedule checks and an additional confirmation step.
Printing the consult summary
Every consultation produces a Consult Summary PDF with the hospital letterhead, the doctor's details, and a clean SOAP record. Click Print at the bottom of the consult page; or hand the patient a QR code that opens the summary on their phone.
Follow-ups
Set a follow-up date inside the plan section. The system creates a proposed appointment slot and sends an SMS reminder 24 hours before the visit.