Consultation & e-Prescription
Document the visit with structured notes, build formulary-aware prescriptions with interaction checks, and route an e-signed FHIR R4 script straight to pharmacy.
The consultation workspace is where the doctor documents the encounter and issues orders. It combines structured clinical notes, a prescription builder that understands clinical intent, safety checks, and reusable templates, with an optional AI Scribe to cut typing.
Structured consultation notes
Consult notes are captured as discrete fields rather than free text alone, so the record stays legible and reportable. A typical note records:
- Symptoms: the presenting complaint and history.
- Vitals: measured observations for the visit.
- Diagnosis: the clinician's assessment.
The prescription builder
Prescriptions in DoctSoft capture clinical intent, not a pharmacy SKU. The doctor prescribes the medicine as a clinical order and the pharmacy later maps that intent to an actual stocked product and batch. Each line specifies:
| Field | Meaning |
|---|---|
| Generic | The drug's generic (molecule) name. |
| Strength | e.g. 500 mg. |
| Form | e.g. tablet, syrup, injection. |
| Route | e.g. oral, IV, topical. |
| Dose | Amount per administration. |
| Frequency | How often, e.g. twice daily. |
| Duration | How long the course runs. |
The builder is formulary-aware: it suggests entries from your hospital formulary as the doctor types. When a required medicine isn't in the formulary, the doctor can add a custom entry so care is never blocked by a catalogue gap. Because a line is clinical intent and not a specific SKU, the same script can be dispensed from whichever batch the pharmacy has in stock.
Drug–drug interaction checks
As medicines are added, DoctSoft runs drug–drug interaction checks across the prescription and flags potential conflicts, giving the clinician a chance to review before signing.
E-signing and routing to pharmacy
Complete the prescription
Add all medicines with their clinical detail and clear any interaction warnings the doctor chooses to review.
E-sign
The doctor applies their electronic signature to the prescription.
Generate a FHIR R4 record
The signed prescription is produced as a standards-based FHIR R4 record.
Route to pharmacy
The prescription lands in the pharmacy dispensing queue, where staff map each line to stock and dispense.
OPD templates
For visits that recur, such as a standard fever workup or a diabetes review, the doctor can save an OPD template bundling a reusable note plus its order set. Applying a template pre-fills the notes and prescription, so common encounters take seconds while staying fully editable.
AI Scribe
AI Scribe provides ambient documentation: it listens during the consultation and drafts the structured note for the clinician to review and confirm, reducing keyboard time so the doctor keeps attention on the patient. Combine it with OPD templates: let the scribe capture the narrative while the template supplies the standard order set, then review both before e-signing.