Doctor Consultations & Electronic Medical Records (EMR)

Clinical Encounter Workflow#

When a patient is called into the consultation room, the examining doctor accesses the unified Electronic Medical Record (EMR) workspace via hms.consultation.

The encounter is structured around the internationally recognized SOAP (Subjective, Objective, Assessment, Plan) clinical documentation methodology:

flowchart TD
    S["Subjective<br/>Chief complaint & history of presenting illness"] --> O["Objective<br/>Physical exam findings & review of systems"]
    O --> A["Assessment<br/>ICD-10 primary & differential diagnosis"]
    A --> P["Plan<br/>Lab orders, e-prescriptions, admission, follow-up"]

SOAP Documentation Components#

1. Subjective (Chief Complaint)#

The patient’s own description of symptoms, onset, duration, severity, and aggravating/relieving factors. Historical allergies and chronic treatments are cross-referenced automatically from hms.patient.

2. Objective (Physical Examination)#

Documented clinical observations, physical inspection of organ systems (e.g., HEENT, cardiovascular, respiratory, abdominal, musculoskeletal), and synchronized triage vital signs.

3. Assessment (Diagnosis Coding)#

Physicians assign standardized ICD-10 diagnostic codes alongside clinical problem descriptions:

• Primary Diagnosis: Principal medical cause for the current consultation.
• Secondary / Comorbid Diagnoses: Underlying medical conditions (e.g., Type 2 Diabetes, Essential Hypertension).

4. Plan (Interventions & Prescriptions)#

From the single consultation screen, the physician triggers downstream clinical actions:

• Electronic Laboratory Requests: Dispatched directly to the diagnostic lab queue.
• Electronic Prescriptions: Structured medication orders sent to the clinic’s dispensary.
• Medical Sick-Leave Certificates: Official certificates with stamped physician credentials.
• Inpatient Admission Requests: Direct referral to ward bed allocation.