ERPNext Healthcare allows you to record Patient encounters through the Consultation document. You can create a Consultation based on a previously booked Appointment or directly by creating a new Consultation

Healthcare > Consultation > Consultation

If you are creating the Consultation document from an Appointment, Patient and other related data will automatically be populated else you can search the Patient by name, email phone number etc. The Patient Details section will list the latest Vital Signs record of the patient and other information captured in the Patient screen.

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Encounter Impression section allows you to select (or create new) Complaints and your assessment based on the presented complaints. You can opt to include the captured data in Consultation print by selecting the "In Print" flag

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You can prescribe medicines in the Drug Prescription section by selecting the drug codes (Stock Item) and appropriate dosages. If you are not managing Stock and Items are not configured, you can simply enter the Medicine name and strength in the Strength field which will printed.

Prescribing a laboratory investigation is similar and if you have Lab Tests configured, you can select from the list. Or key in the Lab Test name to be printed as part of the Prescription.

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Medical Coding

You can also attach one or more Medical Codes to designate the Diagnosis in the Medical Coding Section. You will have to select the Medical Code Standard you wish to encode the diagnosis and then select the Code by searching the Code itself or the Code Description.

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Next: Medical Record