How to record a new consultation

A consultation (or clinical encounter) is the record of a visit: reason, progress, diagnosis, and plan. It’s saved in the patient’s medical record.

Steps

  1. Open Patients and enter the patient’s profile.
  2. Click New consultation.
  3. Write the reason for visit in the patient’s own words.
  4. Complete the clinical note in SOAP format: subjective, objective, assessment, and plan.
  5. Add the diagnosis (ICD-10), and if applicable, prescriptions, exam orders, and RIPS data.
  6. Save. The consultation remains as a draft until you sign it.

With AI

  • Improve with AI: in the note fields, draft or polish text with AI.
  • Suggest exams: AI proposes exams based on the reason and diagnosis.
  • AI scribe: let AI listen to the consultation and create the draft (see the dictation and scribe guide).

Tip

You can dictate the note by voice or use the AI scribe to draft the SOAP from the conversation. Always review the draft before signing.