Writing a consultation note
The structured fields, the free-text box, why a billable consultation needs a coded diagnosis, and how to amend a note afterwards.
2 min read
The fields
Presenting complaint · History · Examination · Assessment · Plan — the ordinary shape of a note, one box each. None is compulsory; fill what is useful for this patient.
Free text (kept as typed) is exactly that. Nothing is reformatted or interpreted. It is there because no set of boxes ever fits every consultation, and a clinician forced into boxes that do not fit writes a worse note.
Start from last plan, at the top right, brings forward the plan from this patient's previous consultation, for a review where most of it still stands. Read it before you save — carrying forward a plan you have not checked is the one real risk of the shortcut.
The diagnosis
A billable consultation needs at least one ICD-10 diagnosis. Start typing in the Diagnosis box and search by name or by code.
Free text may stand beside a code, never instead of one. That is deliberate: a coded diagnosis is what lets the hospital count its own work, answer an HMO, and report to the health authority. A note that says "malaria" in prose and carries no code is invisible to every one of those.
If nothing fits properly, choose the nearest code and say what you actually mean in the free text. Both are kept.
Saving
Save note records it, with your name and your council number — taken from your staff record, not typed. The note is now part of the patient's record and it will not be edited.
Amending
Amend note on a saved note writes a new one that points at the original. Both stay visible, each with its author and time.
Use it when you were wrong, when a result changes the assessment, or when you left something out. Do not use it for typing errors nobody would misread — every amendment is a small flag to a later reader, and flags that mean nothing make the ones that matter harder to see.
While offline
Everything here works with no connection at all. The note is recorded on the machine as you save it and joins the queue to be sent on.
What you cannot see while offline is what somebody wrote on another machine since you last synced — which is what the banner on the clinical summary is telling you.