Prescriptions & diagnoses

This page covers the prescribing and ordering side of an outpatient encounter: writing a prescription with dosing, coding diagnoses to ICD-10, raising lab and imaging orders, making referrals, and how clinical decision support (CDS) alerts — interaction, allergy, dose and duplicate-therapy checks — fire as you order. These records hang off the consultation but each has its own list and lifecycle.

Where to find it

• Outpatient → Prescriptions — all prescriptions (model hms.prescription).
• Outpatient → Diagnoses — the diagnosis register (model hms.diagnosis).
• Outpatient → Referrals — inbound and outbound referrals (model hms.referral).
• Outpatient → Formulary and Outpatient → Drug Interactions — the master data behind prescribing checks; Outpatient → Seed Drug Interactions loads a starter set.
• CDS rules and fired alerts live under HMS Core → Clinical → Clinical Decision Support (Rules, Alerts, Order Sets, Preventive Care, Appropriateness Criteria).

In practice you create most of these from inside the consultation tabs or the Chart Desktop; the menus above are for review and management.

Before you start

• Populate the Formulary so drugs can be searched and so the “formulary only” restriction is meaningful.
• Seed Drug Interactions so interaction checks have data to work against.
• Make sure the ICD-10 catalogue is loaded for diagnosis coding.
• Configure CDS Rules and Override Reasons if you want decision-support alerts and governed overrides.

Step-by-step: write a prescription

1. From the consultation’s Prescriptions tab (or Outpatient → Prescriptions → New), create a prescription. Patient, doctor and facility are inherited from the consultation; it opens in Draft.
2. Add one or more medication lines. For each line set the drug, dose and dose unit, frequency, route, duration (days) and any patient instructions; the quantity is captured per line.
3. As you add drugs, interaction warnings are surfaced on the line and summarised on the prescription. If a drug is outside the formulary or interacts, record an override justification where required.
4. Set the priority (Routine, Urgent or Stat) and add prescriber notes or patient instructions.
5. Press Activate to move the prescription to Active, then Send to Pharmacy so the dispensing team can pick it up. Print Prescription produces a paper copy.
6. As pharmacy dispenses, the prescription moves to Partially Dispensed and then Dispensed; unfilled prescriptions Expire after their validity date.

Prescription states & priority

Priority can be Routine, Urgent or Stat. A prescription is flagged automatically when it contains a controlled substance.

Dosing codes: frequency & route

Each prescription line is written with a coded frequency and route so the label, the pharmacy pick and any interaction logic all read the same dosing. The values you can choose are:

Dose units available on a line are mg, g, mcg, ml, IU, units, tablet(s), capsule(s), drop(s), puff(s) and sachet(s).

Diagnoses (ICD-10)

On the consultation’s Diagnoses tab, add each diagnosis against an ICD-10 code. Set the type — Primary, Secondary, Differential or Provisional — and, where relevant, the severity (Mild, Moderate, Severe), onset and resolved dates. The consultation rolls the primary diagnosis and a code summary up to the encounter automatically.

Lab & imaging orders

Raise investigations from the consultation’s Lab & Imaging tab with Order Lab Tests and Order Imaging, or from the order panel of the Chart Desktop. Orders are linked back to the encounter and the consultation shows live counts of outstanding lab requests and imaging orders via its stat-buttons. Results flow back to the ordering clinician through the laboratory and radiology areas of the suite.

Referrals

From the Referrals tab, create a referral with a reason (required), a specialty (General Practice, Internal Medicine, Pediatrics, Obstetrics and Gynaecology, Surgery, Cardiology and many more), and an urgency of Routine, Urgent or Emergency. A referral may be internal (to a staff member) or external (named provider and contact). It progresses through Requested → Accepted (or Declined) → Completed, and can be Cancelled. Use Send Referral to transmit it and Print Referral for a copy; the receiving side records response notes and dates.

CDS alerts & overrides

Clinical Decision Support watches ordering events and fires alerts. Rules are categorised — Allergy Check, Drug-Drug Interaction, Drug-Disease Interaction, Dose Check, Duplicate Therapy, Preventive Care Reminder, Order Set Recommendation, Diagnosis Suggestion, Lab Follow-up, Imaging Appropriateness and Cost Alert — and carry a severity:

A fired alert moves through Active → Acknowledged, or is Overridden (with a governed override reason), Dismissed or Expired. Override reasons are maintained under Clinical Decision Support → Configuration → Override Reasons, and rules cite an evidence level and knowledge source for audit.

CDS rule categories & triggers

Every decision-support rule belongs to a category and fires on a defined clinical event. The category tells the clinician what kind of check fired; the trigger tells the configurator when it runs.

Roles & access

Prescribing, diagnosing, ordering and referring are Doctor-group actions. Pharmacist receives and dispenses prescriptions. CDS rule authoring and override-reason maintenance are administrative/managerial tasks.

Prescription line field reference

Reports & review

Each area keeps its own list for review. Outpatient → Prescriptions shows prescribing activity and dispensing status; filter to Active to see what pharmacy still owes, or to Expired to find scripts that were never filled. Outpatient → Diagnoses is the morbidity register — group by ICD-10 code to report disease burden. Outpatient → Referrals shows outbound demand by specialty and urgency and tracks turnaround from request to completion. On the CDS side, Clinical Decision Support → Alerts records every fired alert and its outcome (acknowledged, overridden, dismissed), which is the evidence trail for safe-prescribing governance and override review.

Tips & troubleshooting

Related

• Consultations
• The Chart Desktop
• AI clinical tools
• Outpatient & Clinical overview