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Doctor Consultation & Clinical Care (CPOE)

This section describes the workflow for medical practitioners conducting outpatient consultations, documenting structured 3-step encounters, assigning ICD-10 diagnoses, checking formulary stock, authoring electronic prescriptions with digital signatures, and placing laboratory and imaging orders.

1. Before You Begin​

  • Authorized Roles: Attending Doctor, Specialist, Surgeon, Medical Officer.
  • Clinical Principle: All consultations update the patient's continuous longitudinal medical record. Prescriptions are validated in real time against formulary stock availability.

2. Step-by-Step Clinical Consultation Workflow​

graph LR
    A[1. Review Patient Chart] --> B[2. Document Encounter: SOAP & ICD-10]
    B --> C[3. Place Orders: Rx, Labs, Imaging]
    C --> D[4. Finalize & Sign Off Encounter]

Step 1: Pre-Consultation Chart Review​

Before writing a single note or placing any clinical order, perform the pre-consultation review:

  1. Patient Banner Verification: Confirm patient's name, date of birth, and Moana Patient ID on the banner at the top of the screen.
  2. Allergy Check: Review the active allergy list on the banner — note any documented allergies before prescribing.
  3. Medications Review: Review current active medications on the Medications tab.
  4. Pending Results: Check pending diagnostic results in the Results tab — verify if new results returned since the previous encounter.
  5. Clinical History: Review the problem list, past diagnoses, and previous SOAP notes.
Patient longitudinal clinical summary and alert header
Patient longitudinal clinical summary and alert header🔍 Click to enlarge

Step 2: SOAP Note — Structured Clinical Documentation​

Click + New Visit / Consultation / SOAP Note to open a new clinical encounter:

  1. SUBJECTIVE: Document patient's reported symptoms in their own words — onset, duration, character, and associated complaints.
  2. OBJECTIVE: Document physical examination findings, vital signs, and observed clinical appearance.
  3. ASSESSMENT: Enter the ICD-10 coded diagnosis. Type a keyword or code to select from the pre-loaded formulary list. Free-text diagnosis is not accepted as the official coded entry. Optional: enter pain score (0–10).
  4. PLAN: Detail treatment plan, orders to be placed, disposition decision, and follow-up instructions.
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IMPORTANT:

SOAP Note Rule: All Four Sections Required The system strictly enforces that all four sections (Subjective, Objective, Assessment, Plan) must be non-empty before the note can be submitted. ICD-10 diagnosis coding is mandatory in the Assessment section. If a section cannot be clinically completed, document the clinical reason why within that section.

3-Step Clinical Encounter Form with ICD-10 Search
3-Step Clinical Encounter Form with ICD-10 Search🔍 Click to enlarge

Step 3: Unified Order Entry — Prescriptions, Lab, Imaging & Referrals​

All clinical orders are placed from the unified Orders screen:

D1 — Electronic Prescriptions​

  1. Click Prescriptions → + Prescribe Medication.
  2. Select the drug from the hospital formulary. Enter dosage, route, frequency, and duration.
  3. The system checks for drug-allergy and drug-drug interactions, displaying warnings in the System Warnings panel.
  4. Prescribing Advisory vs Dispensing Gate: Warnings at prescribing are advisory — they do not block signing. The enforced hard-stop gate is at the Pharmacy dispensing stage. Always review patient allergies.
  5. Authorize using the digital signature pad. The prescription enters the Pharmacy Dispensing Queue.
Electronic Prescription Pad with Stock Check & Digital Signature
Electronic Prescription Pad with Stock Check & Digital Signature🔍 Click to enlarge

D2 — Laboratory Orders​

  1. Click + Order Lab Test. Select the test from the LOINC-coded laboratory catalog.
  2. Set priority: Routine, Urgent, or STAT.
  3. Enter clinical indication (mandatory — transmits to Moana-LIS via FHIR ServiceRequest).
  4. Important Connectivity Rule: Laboratory orders cannot be placed while the workstation is offline — the request fails outright. Use paper lab request forms during connectivity outages.

D3 — Diagnostic Imaging Orders​

  1. Click + Order Imaging. Select modality (X-Ray, CT, Ultrasound, MRI).
  2. Enter clinical indication and contrast requirements.
  3. Order appears on the Radiology worklist and links to PACS studies.

D4 — Specialty Referrals​

  1. Click Refer. Select the receiving clinical specialty or referral health facility.
  2. Enter clinical indication and urgency level. The referral routes to the receiving team's intake queue.

Step 4: Reviewing Results & Critical Result Acknowledgment​

Results from laboratory and radiology appear in the patient's Results tab once verified and released:

⚡
IMPORTANT:

Patient Safety Checkpoint: Critical Result Acknowledgment When a critical laboratory or radiology notification appears:

  1. Respond immediately. Open the result, review values, and confirm patient's clinical status.
  2. Acknowledge the alert in the system.
  3. Follow direct verbal communication protocols with the diagnostic department regardless of electronic acknowledgment.

3. Clinical Training Scenario​

Scenario D1 — Known Allergy at Prescribing​

  • Clinical Setup: Doctor opens the chart of a patient with a documented penicillin allergy and attempts to prescribe amoxicillin.
  • System Action: System displays a drug-allergy advisory banner in the System Warnings field.
  • Doctor Action: Doctor reviews advisory, recognizes cross-reactivity, and selects an alternative (e.g., Azithromycin).
  • Expected Outcome: Advisory displayed; safe alternative prescribed; order routes to pharmacy without a dispensing hard stop.

Step 6: Patient Disposition & Encounter Sign-Off​

  1. Determine patient disposition:
    • Discharge Home: Prescribe take-home medications and schedule follow-up.
    • Inpatient Admission: Select target ward and care level.
    • Inter-Facility Referral: Package clinical summary and transmit to referral center.
    • Surgical Theatre: Book operating theatre suite.
  2. Click Finalize Encounter.

3. Workflow Result & Departmental Handoff​

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Expected Result:

The clinical encounter is permanently committed to the longitudinal medical record. Prescriptions populate the Pharmacy Clinical Verification Queue; Lab orders route to LIS Sample Collection; and Inpatient requests appear on the Bed Command Center.