In this article
The Consultation screen is where the doctor completes a visit: history, SOAP notes, diagnosis, procedures, prescription, and diagnostic orders on a single screen.
Layout (desktop or landscape tablet)
- The patient banner is always at the top: name, medical record number (MRN), age, sex, payer, and allergy chip. Check the banner before writing to avoid documenting on the wrong patient.
- Left column: visit history and allergies.
- Center: SOAP, diagnosis, procedures.
- Right: prescription and invoice summary.
- On a portrait tablet, the left and right columns become tabs.
Steps
- The nurse opens the patient's visit from the queue and fills in the history taking and vital signs (units are shown; out-of-range values are flagged).
- The doctor calls the patient and opens the Consultation screen.
- Choose a SOAP template for the clinic unit, then complete Subjective, Objective, Assessment, and Plan.
- Record the diagnosis (
Alt+D); a primary diagnosis is required before the visit can be closed. - Add procedures, a prescription (
Alt+R), and lab or radiology orders if needed. - Close the visit (
Alt+T). The note is signed electronically, the charges go to the cashier, and the data is sent to SATUSEHAT (the national health data platform).
Autosave
Notes are saved automatically about every 5 seconds; an indicator shows "Saved 10:42". You can also save with Ctrl+Enter.
AI Scribe and history summary
When enabled, AI Scribe prepares a draft SOAP note from a voice recording (with the patient's consent) and a summary of the patient's history. You must review and edit the draft; clinical decisions remain with the doctor.