Consultations
A consultation is the clinical record of a single outpatient encounter, captured as a structured SOAP note. This page covers the full lifecycle: starting a consultation from a visit, recording the Subjective, Objective, Assessment and Plan, adding diagnoses, prescriptions, orders and referrals, and signing the note — plus how to amend a signed note when something needs to change.
Where to find it
- Outpatient → Consultations opens the consultation list (model hms.consultation). Each row is one encounter; rows are colour-coded — draft in blue, completed in green, amended muted.
- To consult live on a single screen instead of the form, use Outpatient → Chart Desktop → Open Chart (select consult) — see The Chart Desktop.
- Outpatient → SOAP Templates manages the templates that pre-fill the four SOAP fields.
Visit → encounter
Every consultation belongs to a Visit. The visit is the patient’s episode of care for the day; the consultation is the doctor’s clinical entry within it. When you create a consultation you must pick the visit, and the patient, department and facility are pulled from it automatically. A visit moves through Draft → Triaged → In Consultation → Services → Billing → Discharged → Closed; the consultation cannot be added as a draft to a visit that is already closed or discharged.
Before you start
- The patient must already have an open visit (created at Reception).
- Your user needs an HMS staff record with the doctor role — the Doctor field defaults to you.
- For prescribing and ordering to be useful, the Formulary, Drug Interactions and ICD-10 catalogue should be populated first.
Step-by-step: conduct a consultation
- From Outpatient → Consultations, click New. Select the patient’s Visit; patient, department and facility fill in. Confirm the Doctor and the Consultation Date. The new record opens in Draft.
- (Optional) Pick a SOAP Template and press Apply Template to pre-fill the SOAP fields. Existing text is preserved — templates only fill blank fields.
- Fill the four note tabs: Subjective (history, chief complaint, HPI, review of systems), Objective (examination findings, vitals, measurements), Assessment (clinical impression, differentials) and Plan (investigations, medications, follow-up).
- On the Diagnoses tab, add one or more diagnoses coded to ICD-10; mark one as Primary. On Prescriptions, add the medications (see Prescriptions). On Referrals, raise any referral.
- On the Lab & Imaging tab, press Order Lab Tests or Order Imaging to raise orders linked to this encounter. The stat-buttons at the top track the lab-request and imaging counts.
- Attach a Voice Note or extra notes on the Attachments & Notes tab if needed.
- When the encounter is finished, press Complete. The consultation moves to Completed and the end time is stamped (the duration is computed from start to end).
- After completion you can press Print Note for a paper copy or Send to Patient Portal to publish a visit summary to the patient.
Step-by-step: amend a signed note
A completed note is not edited in place — it is amended so the original record is preserved for audit.
- Open the completed consultation and press Create Amendment. A new linked consultation is created that references the original through the Amendment Of field; the original is marked Amended.
- Edit the amendment’s SOAP fields, diagnoses or plan, then Complete it.
- The Amendment Count on the original tracks how many times it has been amended; managers can use Reset to Draft if a record genuinely needs reopening.
Field reference
| Field | Meaning | Required |
|---|---|---|
| Reference | Auto-generated consultation number (unique per company). | Auto |
| Visit | The visit this encounter belongs to; sets patient, department, facility. | Yes |
| Doctor | Clinician; defaults to the logged-in user’s staff record. | Yes |
| Consultation Date / End Date | Start and end of the encounter; duration is computed in minutes. | Start: yes |
| SOAP Template | Optional template to pre-fill the SOAP fields. | No |
| Subjective / Objective / Assessment / Plan | The four SOAP note sections. | No (clinical) |
| Diagnoses | ICD-10 coded diagnoses; one may be flagged Primary. | No |
| Prescriptions / Referrals | Medications and referrals raised in this encounter. | No |
| Voice Note | Optional audio recording of the encounter. | No |
| State | Draft, Completed or Amended. | Auto |
Consultation states
| State | Meaning |
|---|---|
| Draft | Being written; fully editable. |
| Completed | Signed and part of the record; edit only by amendment. |
| Amended | A later amendment supersedes this note. |
Diagnosis reference
Each diagnosis line on a consultation is coded to ICD-10 and classified by type and, optionally, severity. The classification drives morbidity reporting and tells the rest of the chart which problem is the principal one.
| Field | Values | What it means |
|---|---|---|
| Type | Primary, Secondary, Differential, Provisional | How firmly the diagnosis is established and whether it is the principal problem; one diagnosis is normally flagged Primary. |
| Severity | Mild, Moderate, Severe | Optional clinical grading of the condition. |
| Onset / Resolved Date | Dates | When the condition began and, if applicable, when it resolved. |
| Clinical Notes | Free text | Supporting detail for the coded problem. |
SOAP template & smart-text categories
Templates and smart-phrases that pre-fill the note are organised by the part of the SOAP record they belong to, so a clinician can pull the right skeleton for the section they are writing.
| Category | Fills |
|---|---|
| History of Present Illness | Subjective |
| Physical Examination | Objective |
| Assessment / Diagnosis | Assessment |
| Plan / Orders | Plan |
| Progress Note | Follow-up entries |
| Discharge Summary | End-of-episode notes |
| Procedure Note | Procedure documentation |
| Consent / Disclosure | Consent text |
Configuration
Build a library of SOAP Templates (Outpatient → SOAP Templates) for common presentations so clinicians start from a structured skeleton rather than a blank field. Feature switches for the area are under Outpatient → Configuration → Settings.
Roles & access
The Complete, Create Amendment and Apply Template actions are restricted to the Doctor group. Reset to Draft is restricted to the HMS Manager group. Nurses can read consultations; the patient portal sees only the published summary.
Finding and reviewing consultations
The Consultations list is the review and reporting surface for clinical activity. The search view ships ready-made filters — Draft, Completed, Amended, My Consultations, Today and This Week — and group-by options for Doctor, Department, State and Date. A clinician opens My Consultations · Today to clear the day’s work; a supervisor groups by Doctor to compare workload, or by State to find drafts that were never completed. Because every consultation carries its visit, patient, department and computed duration, the same list answers throughput and audit questions without a separate report. Rows are colour-coded so completed, draft and amended encounters are distinguishable at a glance.