See a patient and write a prescription

The doctor's OPD visit step by step - call the patient, check vitals and allergies, write notes and diagnosis, prescribe, order tests, set the follow-up, then sign and print.

This is the doctor's part of an OPD visit, from calling the patient to handing over the printed prescription.

The consultation screen with vitals, notes, diagnosis and the prescription grid

Before you begin

• Your login is linked to your doctor profile, so your patients show on My Day.
• The patient has a token in your queue. See Book an OPD visit and print the parchi.
• Your role may create and sign consultations. See Users & Roles.

Where to find it

Open Outpatients (OPD) → Work → My Day, then click Consult on the patient.

Call the patient

1. On My Day, click Call next.
2. Click Consult on the patient in My Queue.

The consultation opens with the patient's details on the left. Vitals recorded at the desk are already there.

Check before you start

1. Read the Allergies strip. Click + to add one the patient tells you about.
2. Check the Vitals and complete any that are missing.
3. Read Medical History for earlier visits in any department.

Write the notes and diagnosis

1. Type the Chief Complaint, History and Examination.
2. Fill in the Clinical Assessment form, if your department has one.
3. Under Diagnosis, search ICD-10 or type your own and press Enter. The first diagnosis is the primary one.

Prescribe

1. Choose From Inventory or Free Text under Medicine source.
2. Click Add Drug, or click a medicine under Quick add.
3. Fill in Dose, Route, Frequency, Days and Qty, and instructions such as after meals.
4. Repeat for each medicine. Click Repeat on an earlier visit to copy its medicines.

Watch for a red Allergy alert. It names any medicine that matches the patient's allergies.

Order tests and set the follow-up

1. Under Recommended Tests / Investigations, add each test and click Send to Lab. Imaging exams go to radiology on the same click.
2. Type the Advice.
3. Set the Follow-up date, or the number of days in or in (days).

Sign and print

1. Click Save & Sign.
2. The prescription prints. Use Print Rx to print another copy on A4 or A5.

Signing completes the visit, serves the token and sends the prescription to the pharmacy. The patient leaves your queue.

If the patient needs more

• Admit, Book OT or Send to ER under Doctor's orders. See OPD Consultation.
• Refer to another department. The button shows only when your role has the Create / Update Referrals permission. See Referrals.

Common questions

The patient's results came back after I signed. On the signed consultation, the results show at the top with an Addendum box. Type your note and click Add to note. The signed note itself does not change.

The prescription printed without my medicines. Rows without a drug name are dropped. Check each row has a medicine before signing.

The pharmacy says the prescription has not arrived. It is still a draft. Open it and click Save & Sign.