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Doctor Consultation & Clinical Care (CPOE)

The Doctor Consultation & Clinical Care module in MOANA provides physicians, surgeons, and specialists with an integrated Computerized Physician Order Entry (CPOE) and clinical charting environment. It unifies longitudinal medical record reviews, structured clinical encounters (SOAP), diagnostic ordering, electronic prescribing with automated safety checks, surgical bookings, and specialized inpatient rounds.

Doctor Clinical Command Dashboard showing active queue, pending diagnostic results, and critical alert feeds.
Doctor Clinical Command Dashboard showing active queue, pending diagnostic results, and critical alert feeds.🔍 Click to enlarge

1. Clinician Command Dashboard​

Upon logging into the clinician portal, the attending doctor is greeted with an actionable operational dashboard tailored for clinical throughput and patient safety:

  • Today's Patient Queue: Displays all scheduled, checked-in, and walk-in patients waiting for consultation. Shows patient arrival times, triage priority levels (e.g., Emergency Red, Urgent Yellow, Normal Green), and live elapsed waiting times.
  • In-Progress Consultations: Quick-resume active clinical notes that are currently open.
  • Critical Lab & Imaging Feeds: Instant alerts for panic lab values (e.g., Potassium < 2.5 mEq/L, Severe Sepsis Lactate) or abnormal radiological findings requiring immediate clinician acknowledgment.
  • Clinical Task Center: Pending prescription refills, specialist referral responses, counter-signatures, and laboratory result sign-offs.

2. Longitudinal Patient Banner & Pre-Consultation Review​

Before initiating a new encounter or writing prescriptions, the clinician reviews the Master Patient Banner anchored at the top of the clinical chart:

Longitudinal Master Patient Banner displaying demographic summary, allergy chips, and active problem lists.
Longitudinal Master Patient Banner displaying demographic summary, allergy chips, and active problem lists.🔍 Click to enlarge

Mandatory Pre-Consultation Safety Checklist:​

  1. Patient Identification: Verify the patient's full name, age, biological sex, and permanent MOANA Health ID.
  2. Active Allergy Banner: Review color-coded allergy badges (e.g., 🔴 Penicillin (Anaphylaxis), 🟡 NSAIDs (Gastritis)).
  3. Current Active Medications: Cross-reference existing inpatient or outpatient prescriptions to prevent therapeutic duplication.
  4. Vitals & Triage History: Review baseline vitals recorded by the triage nurse (Blood Pressure, Heart Rate, SpO2, Temperature, Respiratory Rate, and Modified Early Warning Score - MEWS).
  5. Past Medical History & Problem List: Review chronic conditions (e.g., Type 2 Diabetes, Hypertension, Chronic Kidney Disease).

3. The 3-Step Clinical Encounter Workflow​

MOANA organizes clinical documentation into a streamlined 3-step structured workflow:

graph TD
    A[1. Visit Metadata & Vitals] --> B[2. Structured SOAP Note & ICD-10]
    B --> C[3. Unified Order Entry CPOE]
    C --> D[4. Disposition & Digital Sign-Off]
    
    C --> C1[Electronic Prescriptions]
    C --> C2[Laboratory Orders LIS]
    C --> C3[Radiology & PACS Orders]
    C --> C4[External Diagnostics]
    C --> C5[Operating Theatre OT Booking]
    C --> C6[Specialty Referrals]

Step 1: Visit Metadata & Encounter Details​

  1. Select the Encounter Type:
    • Outpatient Consultation (OPD): Routine or scheduled clinic visit.
    • Emergency Department Encounter: Acute resuscitation or urgent intake.
    • Inpatient Ward Round: Daily progress evaluation for hospitalized patients.
    • Telemedicine Consultation: Virtual video or telephone consult.
  2. Enter the Chief Complaint and recorded duration of onset.
  3. Record the Pain Scale Score (0–10 scale using the Wong-Baker visual reference).

Step 2: Structured SOAP Note & ICD-10 Diagnostic Coding​

MOANA enforces structured documentation based on the universally accepted SOAP framework:

Structured SOAP Clinical Encounter Form with ICD-10 Diagnostic Search Engine.
Structured SOAP Clinical Encounter Form with ICD-10 Diagnostic Search Engine.🔍 Click to enlarge
  1. SUBJECTIVE (S):
    • Document the patient's narrative, history of present illness (HPI), review of systems (ROS), and symptom progression in their own words.
  2. OBJECTIVE (O):
    • Record physical examination findings (General appearance, HEENT, Cardiovascular, Respiratory, Abdominal, Neurological, Musculoskeletal).
    • Review attached point-of-care diagnostics or bedside vitals.
  3. ASSESSMENT (A) — ICD-10 Diagnosis Search:
    • MOANA features an intelligent ICD-10 search engine. Clinicians can type either standard diagnostic codes (e.g., J18.9, I10, E11.9) or natural clinical terms (e.g., Lobar Pneumonia, Essential Hypertension, Type 2 Diabetes).
    • Multiple diagnoses can be coded, designating one as Primary Diagnosis and additional entries as Secondary / Comorbid Diagnoses.
  4. PLAN (P):
    • Summarize the therapeutic strategy, patient education, dietary recommendations, lifestyle modifications, and follow-up timeline.

:::important Mandatory SOAP Section Rule To ensure medical-legal integrity and accreditation compliance, MOANA requires all four SOAP sections (Subjective, Objective, Assessment, and Plan) to be non-empty, and at least one official ICD-10 coded diagnosis must be assigned in the Assessment section before the encounter can be signed. :::

Step 3: Unified CPOE Order Entry Hub​

The unified order entry interface allows doctors to author all clinical, diagnostic, pharmaceutical, and surgical orders in a single screen:

Unified CPOE Order Entry Screen for Prescriptions, Laboratory, Radiology, and Surgical Orders.
Unified CPOE Order Entry Screen for Prescriptions, Laboratory, Radiology, and Surgical Orders.🔍 Click to enlarge
Unified CPOE Order Entry Screen for Prescriptions, Laboratory, Radiology, and Surgical Orders.
Unified CPOE Order Entry Screen for Prescriptions, Laboratory, Radiology, and Surgical Orders.🔍 Click to enlarge

1. Electronic Prescriptions (e-Prescribing)​

  • Formulary Stock Validation: As you search for medications, MOANA displays real-time pharmacy inventory levels and available dosage forms.
  • Structured Dosing: Specify dosage (e.g., 500 mg), route (Oral, IV, IM, SC, Topical), frequency (OD, BD, TDS, QDS, PRN), and treatment duration (Days / Weeks).
  • Clinical Decision Support (CDS):
    • Drug-Allergy Alerts: Warns immediately if a prescribed medication cross-reacts with documented patient allergies.
    • Drug-Drug Interactions: Evaluates concurrent active medications against clinical pharmacology interaction databases.
  • Favorite Medications & Order Sets: Clinicians can save frequently used prescription regimens (e.g., Standard CAP Regimen, Post-Op Analgesia Protocol) for one-click re-use.
  • Digital Signature: Authorize prescriptions using the secure biometric / PIN digital signature pad.

2. Laboratory Diagnostic Orders (Moana-LIS)​

  • Select tests from the LOINC-coded hospital laboratory catalog (e.g., Full Blood Count, Renal Function Panel, Liver Enzymes, Blood Culture, Lipid Profile).
  • Designate order priority: Routine, Urgent, or STAT.
  • Enter clinical indications and specific collection instructions for phlebotomy.

3. Radiology & Medical Imaging Orders (PACS)​

  • Order diagnostic imaging across all available hospital modalities: X-Ray, CT Scan, Ultrasound, MRI, Mammography, Fluoroscopy.
  • Specify anatomical region, views required, and whether IV contrast is indicated (with mandatory eGFR / Renal function verification for contrast studies).

4. External Diagnostic Orders​

  • For specialized tests not performed on-site (e.g., Histopathology, Genomic Sequencing, Specialized Toxicology), route orders to accredited third-party partner laboratories.

5. Operating Theatre (OT) Surgical Suite Bookings​

  • For elective or emergency surgical cases, launch the Schedule Theatre Booking wizard.
  • Specify planned procedure, surgical specialty, lead surgeon, anaesthesia type (General, Spinal, Regional, Local), estimated duration, and blood cross-match requirements.
Operating Theatre Surgical Booking Wizard with team assignment and anaesthesia prerequisites.
Operating Theatre Surgical Booking Wizard with team assignment and anaesthesia prerequisites.🔍 Click to enlarge
Operating Theatre Surgical Booking Wizard with team assignment and anaesthesia prerequisites.
Operating Theatre Surgical Booking Wizard with team assignment and anaesthesia prerequisites.🔍 Click to enlarge

6. Specialty Referrals & Consultations​

  • Generate internal inter-departmental consultations (e.g., Cardiology Consult for Inpatient) or inter-facility referrals to regional tertiary hospitals.
  • The referral package automatically bundles the active SOAP note, vitals, diagnostic results, and medication list.

4. Specialized Inpatient & Critical Care Workflows​

ICU Daily Clinical Rounds​

For patients admitted to Intensive Care and High Dependency Units (ICU/HDU), MOANA provides a specialized ICU Rounds clinical charting tool:

ICU Daily Rounds Clinical Form showing organ system review, ventilator parameters, and daily care goals.
ICU Daily Rounds Clinical Form showing organ system review, ventilator parameters, and daily care goals.🔍 Click to enlarge
  • System-by-System Assessment:
    • Neurological: Glasgow Coma Scale (GCS), sedation score (RASS), pupil reactivity.
    • Cardiovascular: Hemodynamic parameters, arterial line readings, central venous pressure (CVP), inotrope/vasopressor titration rates.
    • Respiratory: Mechanical ventilator mode (e.g., SIMV, PRVC, PSV), FiO2, PEEP, tidal volume, Peak Inspiratory Pressure (PIP), arterial blood gas (ABG) trends.
    • Renal & Fluid Balance: 24-hour fluid intake vs. output balance, hourly urine output (mL/kg/hr), continuous renal replacement therapy (CRRT) settings.
    • Gastrointestinal & Nutrition: Enteral vs. Parenteral nutrition rates, gastric residual volumes, bowel sounds.
    • Infectious Disease & Sepsis: Antimicrobial days of therapy (DOT), culture sensitivities, fever spikes, inflammatory markers.
  • Daily 24-Hour Clinical Goals: Set measurable multi-disciplinary targets for weaning, extubation readiness, mobilization, and invasive line de-escalation.

Pediatric Growth & Child Health Tracking​

For pediatric and neonatal consultations, clinicians can access integrated growth charting and developmental milestone records:

  • Longitudinal Growth Curves: Automated WHO percentile charts for Weight-for-Age, Height-for-Age, and Head Circumference.
  • Expanded Immunization Register (EIR): Visual timeline of administered and due childhood vaccines.

5. Diagnostic PACS Image & Report Reviewer​

Clinicians can review diagnostic imaging studies directly within the patient encounter without launching third-party external applications:

Native Diagnostic Imaging Viewer showing DICOM study alongside the Radiologist's verified report.
Native Diagnostic Imaging Viewer showing DICOM study alongside the Radiologist's verified report.🔍 Click to enlarge
Native Diagnostic Imaging Viewer showing DICOM study alongside the Radiologist's verified report.
Native Diagnostic Imaging Viewer showing DICOM study alongside the Radiologist's verified report.🔍 Click to enlarge
  • Side-by-Side Review: View the verified radiologist interpretation alongside the interactive DICOM study.
  • Interactive Toolset: Multi-planar reconstruction (MPR), window width/level presets (Bone, Soft Tissue, Lung), distance measurement, pan, and zoom.

6. Clinical Decision Support (CDS) & Critical Safety Gates​

graph TD
    A[Order Authoring] --> B{Safety Engine Evaluation}
    B -->|Drug Allergy Match| C[🔴 Anaphylaxis / Severe Reaction Warning]
    B -->|Drug Interaction| D[🟡 Pharmacological Interaction Warning]
    B -->|Stock Depleted| E[⚪ Formulary Stock Depleted Alert]
    B -->|Duplicate Therapy| F[🔵 Active Duplicate Prescription Alert]
    
    C --> G[Advisory at Prescribing -> Hard Gate at Pharmacy]
Clinical Decision Support Alert Dialog displaying drug interaction severity and alternative suggestions.
Clinical Decision Support Alert Dialog displaying drug interaction severity and alternative suggestions.🔍 Click to enlarge
  • Prescribing vs. Dispensing Safety Gates: CDS warnings at the prescribing stage are designed to provide clear clinical advisory feedback without unproductively locking the physician. However, high-risk flags automatically flow down to the Pharmacy Verification Queue, where a pharmacist hard-stop gate prevents medication release until safety is confirmed.
  • Critical Panic Result Alerts: When laboratory or radiology tests exceed panic thresholds, the system broadcasts a high-priority banner to the attending doctor's dashboard requiring explicit acknowledgment.

7. Disposition & Encounter Sign-Off​

Upon completing documentation and orders, the clinician designates the patient's disposition:

Disposition PathSystem Actions & Hand-off
Discharge HomeFinalizes outpatient visit, compiles take-home prescription instructions, prints patient summary with QR Health ID, and books follow-up appointment.
Inpatient AdmissionTransmits an electronic admission order with requested ward, bed category, and admitting diagnoses to the Bed Command Center.
Direct to Surgical TheatreFlags emergency or urgent case on the Operating Theatre Live Status Board and alerts the on-duty anaesthetic team.
Inter-Facility TransferGenerates an encrypted electronic referral summary and transmits it to the receiving medical center.

Click "Finalize & Sign Encounter" to commit all notes and orders permanently to the patient's immutable longitudinal electronic health record.