User Guide

Daily clinic workflow for clinicians. How to document encounters fast and find what you need later.

Creating a new encounter

From the Records screen, tap + New Encounter. The encounter form is a single page covering everything from demographics to discharge. Scroll down to fill in each section, or jump between them on the side rail (Mac/iPad).

Patient demographics & auto-MRN generation

At the top of the form, enter:

• First name
• Last name
• Date of birth (or estimated year)
• Sex
• Village or location (optional)

The MRN field auto-generates from name and DOB the moment you fill those out. If the patient has been seen before in your organization, the app detects this and surfaces their prior MRN with a Return Patient badge — tap it to link this encounter to their existing record.

Entering vitals

The Vitals section accepts:

• Temperature — Celsius by default, with a toggle to Fahrenheit
• Blood pressure — systolic / diastolic in two side-by-side fields
• Heart rate
• Respiratory rate
• Weight — kg by default, toggle to lbs if needed
• Height — optional
• SpO2

Out-of-range values (very high BP, fever, low SpO2) are flagged with a colored highlight so they're easier to spot in the record later.

Recording labs

Labs use one-tap buttons to keep entry fast.

Binary tests (POS / NEG)

For tests like malaria RDT, pregnancy, HIV rapid, and so on, tap POS or NEG. Tap again to clear. The app records the result and the timestamp.

Numeric tests

For tests with a numeric result (hemoglobin, glucose, etc.), tap the test name to open a small numeric pad. Type the value and tap Done.

Urinalysis

Urinalysis has a dedicated dipstick panel — leukocytes, nitrites, protein, glucose, ketones, blood, etc. Tap each pad to cycle through Negative, Trace, 1+, 2+, 3+.

Selecting diagnoses

Tap + Add Diagnosis to open the diagnosis picker. You can:

• Pick from a list of presets (your admin curates these)
• Search by typing a few letters of the condition name
• Use the text override to type a free-text diagnosis if it's not in your presets
• Mark a diagnosis as Confirmed, Suspected, or Rule out
• Add multiple diagnoses for one encounter

Adding medications

There are two ways to add medications, optimized for different situations.

Rx presets (fastest)

Rx presets are pre-built prescription bundles for common scenarios — for example, "Malaria — adult" might add artemether-lumefantrine with the right dose, frequency, and duration in one tap. Tap a preset to add the whole bundle to the encounter, then adjust as needed.

Medication builder

For one-off prescriptions or anything not in a preset, tap + Build Medication. The builder walks through:

1. Drug name (search the formulary)
2. Dose (with weight-based calculator if a weight is on file)
3. Route — PO, IM, IV, topical, etc.
4. Frequency — once, BID, TID, QID, q4h, etc.
5. Duration — number of days
6. Notes — anything specific to this patient

The builder checks the formulary in Options → Formulary for available stock or known forms.

Procedures, imaging, surgical encounters

Below the Rx section there are three optional blocks:

• Procedures — pick from your preset list (incision & drainage, suturing, dressing, etc.) and add notes
• Imaging — record what was ordered or done (X-ray, ultrasound) and the finding
• Surgical Encounters — for OR cases. Pick the procedure, surgeon, anesthesia type, and a status (Planned, In Progress, Completed)

Setting referrals with dates

Tap + Add Referral to record any onward referral — surgery day, follow-up clinic, hospital transfer, etc.

• Pick the Referral Type from your presets
• Set a Scheduled Date if you have one
• Add a destination or specialty
• Add notes for the receiving team

Open referrals show up in Scheduling so the team can plan around them.

Save & Next workflow for batch entry

If you're entering a stack of paper forms after a clinic day, use Save & Next at the bottom of the form instead of Save. This:

1. Saves the current encounter
2. Clears the form
3. Pre-fills site, provider, and date from your last entry
4. Puts focus back at the top so you can start typing the next patient

Searching records

From Records, the search box at the top accepts:

• Patient name (partial matches work)
• MRN
• Diagnosis
• Medication
• Site

Below the search box, filter chips let you narrow by date range, provider, site, or diagnosis. Filters stack — so "all malaria-positive patients seen by Dr. Okafor at Site 3" is one search.

Viewing patient history (multi-visit support)

Tap any patient in the records list to see their full chart. Multiple visits show up in chronological order with a summary card for each visit:

• Date and site
• Chief complaint
• Diagnoses
• Medications prescribed
• Open referrals

Tap a visit card to open the full encounter as it was originally written. From the patient header, tap + New Visit to start a fresh encounter linked to the same MRN — useful for return patients.

Marking referrals complete

When a referral is fulfilled — surgery happens, patient is seen at follow-up, hospital transfer is complete — open the patient's chart and find the referral on their visit. Tap the referral card and choose Mark Complete. You can add an outcome note. The referral disappears from the open queue in Scheduling.