Write the consultation note

When you need this

You're seeing the patient and want to write up the visit: why they came, what you found, your assessment and plan, and any diagnoses, medications and lab tests. You can save it as a draft as you go, and sign it when it's complete.

Steps

1. Open the patient's encounter. If there's no note yet, press Start consultation (see Start a consultation). Otherwise press Continue consultation at the top right. The Consultation note opens on the right. A draft you saved before opens where you left it. (Once the visit's note is signed, the header shows End consultation instead: to read or change a signed note, see the last point under If something goes wrong.)
2. Chief Complaint (required): the patient's main reason for the visit.
3. Fill in what applies: History of Present Illness, Review of Systems, Physical Exam Narrative, Assessment and Plan.
4. Under Diagnoses, press Add Diagnosis for each diagnosis: its ICD code and description, and its type.
5. Under Medications, press Add Medication for each one: the medication, dosage, frequency, route and duration.
6. Under Lab Tests, press Add Test for each test, with its priority. Pick the laboratory under Send to laboratory if it goes to one.
7. Save:
   • Save Draft keeps the note to finish later. (When you continue a draft, this button says Save Changes.)
   • Save & Sign finishes the note. Signing adds its diagnoses, medications and lab tests to the patient's record.

To print for the patient, use Download Prescription or Download Lab Request at the bottom of the note.

The lab request you download here is the copy for the patient, an outside lab or a medical aid. It carries your practice's stamp, dated the day of the request. It leaves out the patient's phone number, email and address, and your own phone and email. It isn't a claim: a medical aid needs its claim form as well. The lab's own copy, with the contact details, is printed from the lab request in the lab.

What you should see

A short message shows: "Draft saved" (a new draft), "Note saved" (Save Changes on a draft) or "Note signed" (Save & Sign). The note closes and you stay on the tab you were on.

On Summary:

• The Consultation note card shows the note. A draft has a Draft label beside the card's title.
• A draft's diagnoses, medications and lab tests show in their cards, marked Draft, under the words "In the draft note – added to the record when the note is signed." They become part of the patient's record only when you sign the note.
• Once signed, the Draft labels go and the counts on the tabs go up.

All of the visit's notes are on the Consultation notes tab. Click one to open it.

If something goes wrong

• Save Draft and Save & Sign stay grey: fill in Chief Complaint. They also stay grey while a recording is still saving or being processed: wait for it to finish.
• A message lists what's missing, for example Medication "Amoxicillin": dosage, frequency, route required, Diagnosis "…": type required or Lab test "…": priority required: fill in those fields on the line it names, then save again.
• "Unsaved Changes" when you close the note: you've typed something that isn't saved. Press Cancel to go back and save it, or Yes, close to throw it away.
• There's no Continue consultation button: the visit is finished, or your role can't write notes. If the header shows End consultation on its own, the note is already signed: open the Consultation notes tab and click the note to read it, or press Amend Note in it to correct it.