Clinical Notes & Sessions
Writing session notes, recording vitals, prescriptions, and AI co-pilot features.
Starting a session
A session opens when a patient is IN_CHAIR:
- From the Waiting Room or Calendar, click the patient's name
- Click Start Session — the full session screen opens
- The session has tabs: Notes, Prescription (Rx), Services/Billing, plus specialty-specific tabs for your clinic type
Session notes auto-save to the browser every keystroke. If your browser closes or crashes, your draft is restored when you reopen the session.
Recording vitals
At the top of every session, expand the Vitals panel to record:
- Blood pressure (systolic/diastolic)
- Heart rate
- Temperature (°C)
- SpO₂ (%)
- Weight (kg)
- Height (cm) — BMI calculated automatically
Vitals are stored per-session and trend over time in the patient profile. They are also sent to AI clinical summary generation.
Prescriptions
On the Prescription (Rx) tab:
- Search for a drug by name (generic or brand) — over 5,000 drugs available
- Set dosage, frequency, duration, and route
- Add special instructions (with food, avoid sunlight, etc.)
- Click Check Interactions — the AI reviews the full prescription for drug-drug interactions and contraindications with the patient's known conditions
- Click Save Rx — a print-ready prescription is generated automatically
For pediatric patients, weight-based dosing is calculated automatically based on the patient's current weight. All prescriptions are archived in the patient's medication history.
AI co-pilot
The AI co-pilot is available from the session screen's AI button (top right):
| Function | What it does |
|---|---|
| Clinical Summary | Generates a structured SOAP summary from your notes, vitals, and medications |
| Discharge Summary | Creates a formal discharge summary for hospital transfers or referrals |
| Prescription Review | Checks the full medication list for interactions, contraindications, and dose errors |
| Referral Letter | Drafts a professional referral letter addressed to the receiving specialist |
The AI uses the OpenRouter model chain: GPT-4o-mini → GPT-3.5-turbo → Llama 3.3 70B → Gemma 3 27B. The best available model is used based on response time and availability. All AI outputs are clearly marked as AI-assisted and require clinical review.
Saving and completing a session
When the consultation is complete:
- Review the notes, prescription, and services charged
- Click Complete Session — the appointment status changes to COMPLETED
- An invoice draft is automatically generated from the services listed on the session
- The patient's record is updated with the new session, vitals, prescriptions, and any clinical tool results
- A post-visit WhatsApp/SMS is queued (if configured in Settings → Automation)
Once a session is saved, the notes are locked. You can add an addendum but cannot delete original content (audit trail).