EHR Clinical Consultation

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CLINICAL CONSULTATION

The user do not need to follow any specific order in the consultation. None of the items is mandatory except Consultation Session Information.

Only one clinical consultation session is allowed to be opened at any one time. To start a new consultation session, the previous one, if any, must be ended before a new one can be started.

If this window was closed either intentionally or unintentionally such as when the workstation crashes, the user can still resume the previous open consultation session.


Progress

Click on the Progress link to view the progress of the current consultation.

Complaints

Form to record the reasons for this encounter.

Vital Signs

Form to record patient's vital signs and anthropometric data for charting.

Physical Examination

Form to record physical examination of patient, by anatomical system.

Lab Orders

Form to record lab orders for in-house and external labs.

Imaging Orders

Form to record imaging orders for in-house and external imaging facilities.

Diagnosis (categorised)

Form to add diagnosis, based on category of classification, e.g. ICD-10.

Diagnosis (searchable)

Form to add diagnosis using search terms.

Prescription (categorised)

Form to add prescription, based on drug system of ATC.

Prescription (searchable)

Form to add prescription, based on search terms of generic drug names or indication.

Immunisation

Form to record immunisations for the current clinical session.

Referral

Form to add referral. THIRRA will automatically generate a pre-polutated referral letter.

External Modules

Links to external modules such as Generic Engine for Modules (GEM), etc.

Antenatal

The Antenatal Module is activated if the patient is a female and is passed menarche. The age of menarche can be configured in config.php

Consultation Session Information

The user can change the date and time to back date the session if necessary.


Closing Consultation Session

Click the [Close Consultation] button to end the current consultation session. Clinical details of closed sessions, cannot be modified once the session is ended.

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