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EMR & Diagnosis Coding

The electronic medical record: capture vitals, write SOAP clinical notes, place orders, and code diagnoses to ICD‑11 with AI assistance — all against the current encounter.

Vitals

Medical → EMR → Vitals (/medical/emr/vitals) — Record Vitals for an encounter: temperature, blood pressure, heart rate, respiratory rate, SpO₂, weight/height (BMI), with timestamp. Vitals → Trend (/medical/emr/vitals/trend) plots a patient's blood pressure, pulse, SpO₂, temperature and weight over time as sparkline mini‑charts, so a clinician sees the direction of travel at a glance.

Clinical Notes (SOAP)

Medical → EMR → Notes (/medical/emr/notes) — write a note in SOAP structure:

  • Subjective — chief complaint and history.
  • Objective — examination findings.
  • Assessment — clinical impression.
  • Plan — treatment and follow‑up.

Screenshot: Clinical note (SOAP) — TODO

Orders & Prescriptions

Medical → EMR → Orders (/medical/emr/orders) — place Laboratory, Imaging, Medication, or Procedure orders. Orders move Draft → Active → Completed (or Cancelled); medication orders carry dose, frequency, and route.

When an order becomes Active, it is routed to the fulfilling department automatically: a Lab order creates a requisition on the lab worklist, an Imaging order on the radiology worklist, and a Medication order to the pharmacy dispense queue. Cancelling the EMR order cancels the downstream requisition too (while it is still pending). If an imaging order's free‑text can't be matched to a procedure, you're prompted to raise it manually (pre‑filled) — nothing is silently dropped.

Prescribing is guarded:

  • Prescriber privilege — placing a medication order requires the ordering provider to hold the PRESCRIBE privilege.
  • Formulary advisory — when a hospital formulary is configured, ordering a drug not on it shows a warning but still saves — doctors may prescribe unavailable/off‑formulary drugs.
  • Allergy & interaction checks — the patient's recorded allergies and drug–drug interactions are screened and flagged at prescribe time.

Allergy check on prescribing

Saving a medication order whose drug matches the patient's recorded allergies shows a warning to the prescriber. This is advisory — the hard stop is the dispense allergy gate. See Allergies & Safety.

Prescribing is guarded:

  • Prescriber privilege — placing a medication order requires the ordering provider to hold the PRESCRIBE privilege.
  • Formulary gate — when a hospital formulary is configured, a placed medication order must name a drug on it.
  • Allergy & interaction checks — the patient's recorded allergies and drug–drug interactions are screened and flagged at prescribe time.

Diagnosis coding (ICD‑11, AI‑assisted)

Medical → Diagnosis Codes (/medical/icd-codes) maintains the hospital's ICD catalogue (ICD‑11 preferred, ICD‑10 for legacy claims). When coding a diagnosis, type a free‑text phrase — in English or Nepali (e.g. "खोकी र ज्वरो") — and the AI assistant suggests matching codes.

Screenshot: AI diagnosis-code suggestion — TODO

Loading the full ICD‑11 catalogue (offline)

The catalogue ships with a starter set of common Nepal‑relevant codes. To load the complete WHO ICD‑11 classification, use Import ICD‑11 (top‑right of the Diagnosis Codes list, or /medical/icd-codes/import):

  1. Download the “Simple Tabulation” file from the WHO ICD‑11 (MMS) browser. Not sure of the expected layout? Use Download sample template on the import page to get a small headered TSV showing the exact columns.
  2. Upload it here. The file is parsed entirely offline into this hospital's catalogue — no internet or who.int connection is used at run time.
  3. The import is idempotent: it updates existing codes in place and adds new ones, with a summary (added / updated / skipped). Chapter and block rows set grouping context; only leaf categories become selectable (billable) codes.

New WHO releases

When WHO publishes a newer ICD‑11 version, just download its Simple Tabulation file and upload it again — the catalogue refreshes in place. Tick “Retire codes not present in this file” to also mark codes WHO dropped as Retired (kept for history, never deleted).

Grounded & clinician-confirmed

AI suggestions are grounded to your own ICD catalogue — it never invents codes — and are advisory: the clinician confirms the final code. No patient identifiers are sent to the model (only the diagnosis phrase and candidate codes). If AI is unavailable, a keyword search is used. Every suggestion and the clinician's accept/reject is logged — see Medical AI & Coding.

Follow-up & prescription

  • Follow-up date — set a revisit date on the OPD clinical note. A reminder SMS is queued to the patient (through the notification outbox; it sends once an SMS provider is configured).
  • Print prescription — the patient profile's Print Rx action produces a printable patient prescription listing the active medication orders (drug, dose, frequency, route, prescriber) — a clinic handout, distinct from the pharmacy dispense label.