The consultation

Working through a visit

1Open the patient from the queue. Their allergies and long-term conditions are already on screen.
2Record vitals, if the nurse has not.
3Write the note. Use a template if one fits — templates are text with the gaps marked, not forms.
4Add the diagnosis. Start typing and the list narrows; the ones you use most rise to the top over time.
5Prescribe, if there is anything to prescribe. See the next chapter.
6Press Complete. That writes the note into the record and ends the visit.

Your draft is saved on this computer as you type, every few seconds, before it ever reaches the main PC. A power cut mid-consultation costs you nothing.

Choosing the note template

The picker sits beside Today's note. Klinira ships several — a general consultation laid out as SOAP, a short one for a follow-up, and one or two per kind of clinic — and a clinic can write its own. Changing it changes which boxes the note has; what you have already typed into a box both templates share stays where it is.

The picker disappears once the note has been committed to the record. A saved note cannot be edited, and changing the form under one would quietly drop whatever the new template has no box for.

A note cannot be edited afterwards

Once a note is written into the record it stays exactly as it was. Correcting one writes a new version and marks the old one as superseded; both stay readable, and the record shows who wrote each and when. This is a legal requirement for a medical record in Malaysia, not a Klinira preference.

1Open the visit again and find Correct this note at the foot of the note.
2Show every version first, if you want to see what is already there. Superseded versions stay on the list with the reason each was corrected.
3Edit the note above, say what you are correcting, then save.

A finished visit can still be corrected, and that is deliberate — every other change on that screen stops when the visit ends. A mistake is usually noticed after the patient has gone home, which is exactly what this is for.

Correcting a note needs your password, not a Quick PIN. Somebody signed in with a PIN can read every version and cannot change one.

Correcting a diagnosis

A diagnosis is corrected the same way and for the same reason. Click the one that is wrong, search above for what should have been recorded, say why, and save. The original stays on the record with the word corrected beside it — so anybody reading the visit later can see that it was one condition coded wrongly and not two conditions the patient has.

This matters more than it looks. The diagnosis is what a panel claim is made against, what the chronic register works from, and what your coding report counts. A wrong one left standing beside a right one is counted twice everywhere.

Vitals and the growth chart

The growth chart. WHO reference curves with the child's own measurements plotted on them, and the numbers written on the axis rather than hidden in a hover.

Weight, height and head circumference plot against the WHO curves for the child's age and sex.
Print it for the parent to take home. That is what the chart is mostly for.
Blood pressure, pulse, temperature and oxygen saturation are flagged when they fall outside the usual range for the patient's age.

Alerts do not block you

If you prescribe something the patient is allergic to, or that interacts with what they are already taking, Klinira interrupts, shows you what it found and asks for a reason. Then it records the reason and lets you carry on. It never refuses.

The clinical decision is the doctor's. Software that refuses is software that gets worked around, and a doctor who has learned to work around it has learned to ignore the alerts that matter.

Working offline

A consultation works with the network cable out. The note saves locally and goes to the main PC when the connection returns. What does not work offline is dispensing and billing, and there is a chapter on why.