OPD Consultation

The doctor's consultation screen - vitals, notes, the department's assessment form, ICD-10 diagnosis, prescription, tests, advice and follow-up, then sign and print the prescription.

OPD Consultation is where the doctor sees the patient: vitals, notes, diagnosis and the prescription. Signing it closes the visit, sends the prescription to the pharmacy and prints it for the patient.

The consultation screen with the patient rail, clinical notes, diagnosis and prescription

Before you begin

• The patient has a token or appointment. You open the consultation from Patient Queue, My Day or an incoming referral.
• Your role needs the permission to create consultations. Save & Sign needs the sign permission. See Users & Roles.
• The department's assessment form, the complaint and examination lists and the dose schedules are set up by the hospital. See Presenting Complaints and Dosage Schedules.

Where to find it

Click Consult on a token in Patient Queue or My Day. The menu item Outpatients (OPD) → Work → OPD Consultation has no patient, so it takes you to where the tokens are: My Day if your login is linked to a doctor, otherwise Patient Queue.

The screen

• The left rail: the patient's name, MR number, age, gender and blood group, the Allergies strip, the Vitals, and links to each section. Vitals recorded at the desk are already filled in.
• My Queue at the top: your waiting tokens. Click one to move to that patient.
• Clinical notes: Chief Complaint, History and Examination.
• Clinical Assessment: the department's own form, with tick lists, normal or abnormal findings and measurements.
• Diagnosis: search ICD-10 or type your own. The first one is Primary.
• Medical History: earlier visits in every department, with View, Print and Repeat for their medicines.
• Prescription: the medicines, Recommended Tests / Investigations, Advice and the Follow-up date.

Write the prescription

1. Under Medicine source, choose From Inventory to pick stocked medicines, or Free Text to type any name.
2. Click Add Drug, or a medicine under Quick add.
3. Fill in Dose, Route, Frequency (for example 1+0+1), Days and Qty, and any instructions such as after meals.
4. Repeat for each medicine.

If a medicine matches one of the patient's allergies, a red Allergy alert names it. Click + on the Allergies strip to record a new allergy.

See See a patient and write a prescription for the whole visit step by step.

Order tests

1. Under Recommended Tests / Investigations, click Add and type or pick each test.
2. Choose the Priority and add clinical notes for the lab.
3. Click Send to Lab.

Tests the lab knows become a lab order. Names the lab does not know go to radiology as an imaging order. A message lists anything neither recognised. See Lab Orders and Imaging Orders.

Save, sign and print

• Save Draft keeps your work. The badge stays Draft.
• Save & Sign signs the consultation and prints the prescription. Signing completes the visit and the appointment, serves the token, and issues the prescription to the pharmacy.
• Print Rx reprints it as A4 — full page or A5 — compact.

A signed consultation cannot be changed. When results come back, add a note under Addendum and click Add to note.

Hand the patient on

Under Doctor's orders:

• Admit advises admission with the department, ward type, planned or emergency, the Deposit required and notes. The admission desk sees it filled in. See Admit a patient.
• Book OT puts the patient on the Surgery Waiting List with the planned procedure, side, urgency, target date and anaesthesia.
• Send to ER registers the patient in the emergency department, optionally as a medico-legal case.

Refer sends the patient to another department; it shows only when your role has the Create / Update Referrals permission. See Referrals. Enrol opens a programme such as dialysis or antenatal care, when the hospital runs it.

Common questions

The menu item took me to My Day or the queue. A consultation always starts from a token. Click Consult on the patient's token there.

Save & Sign is missing. Your role cannot sign consultations, or the consultation is already signed. A junior doctor's note may need a consultant's co-sign on My Day.

Can I change a signed prescription? No. Add an Addendum, or write a new consultation if the medicines must change.

The patient is still on the board after signing. The consultation fee is due after the consult. The token is served when the counter collects the fee.

How does the patient get a follow-up? Set the Follow-up date, or the number of days. The patient then appears on Follow-ups for the desk to call.