Diagnostics

When an order lives on paper, every step is a handover. The doctor writes the slip, the nurse tells the patient where to go, the performing site hands the result to the patient, and the patient carries it back to the clinic. One slow step is enough for the doctor to open a follow-up chart with no result in it, and for the cashier to have no idea what was done today.

That is why we put diagnostics inside the electronic medical record flow rather than building a standalone app. The order, the result and the cost all attach to one visit, so whoever opens the chart later sees the full context without asking anyone.

The doctor's exam screen has a dedicated Orders tab for the services and diagnostics to be done in that visit. It sits between the clinical exam and the conclusion, matching how a doctor thinks: after the exam, order what is missing; once results are in, return to conclude and prescribe.

The services ordered come from the service catalog your clinic configures, and each service is tied to a performing department and, if needed, a room. So an order does not have to be typed by name each time, and the same service always carries the same name across cases.

Orders in the software are grouped by the standard electronic-record categories: lab tests (blood, urine, biochemistry, microbiology), imaging (X-ray, CT, MRI, ultrasound), functional tests (ECG, EEG, endoscopy, spirometry), procedures and surgery, and treatment services. Each group has its own label and color so a doctor can tell a lab test from an imaging order at a glance.

The category of an order is inferred from the service type your clinic set in configuration, so the clearer your service-type names, the more accurate the grouping. Orders also carry three priority levels, routine, urgent and emergency, so a case that must be done now is not mixed in with scheduled ones.

• Lab tests, imaging and functional tests: the main diagnostic groups.
• Procedures and treatment services are kept separate from diagnostics.
• Three priority levels: routine, urgent, emergency.

The diagnostic result screen has two modes. In free mode there is a single description box, suited to imaging conclusions written as prose. In template mode, if the service already has a prepared indicator template, the screen shows a table for entering each indicator with its unit and reference range.

Template mode is on by default, and an administrator can turn it off in system configuration to return to the free description box. This replaces typing "Hb 13, WBC 7" on one line: the unit and reference range travel with each indicator, so the next reader does not have to guess.

The indicator table is not preset for every service; your clinic builds it in the CLS Templates area of EMR configuration. That area has four separate permissions, view, create, update and delete, so you can let one clinical lead manage templates while other staff only enter results.

Each indicator in a template can be tagged with a code from the shared Ministry of Health catalog of diagnostic indicators, and the software includes that catalog group for you to choose from. A stable code keeps the same indicator meaning the same thing even when the catalog is updated.

Not every clinic performs all its own diagnostics; many send patients to another facility. For those cases the Documents tab on the patient record accepts lab slips and films from elsewhere, up to 20 MB per file, showing name, size and upload date so you can click to download and review.

Inside the visit screen, diagnostic results also have their own attachments, and access follows the right to open the visit. Once the chart is signed, attachments are locked together with it. Before and after treatment photos use the Images tab organized by folder and are kept apart from diagnostic paperwork.

Services, diagnostics and drugs ordered during the visit are added automatically to the visit total on the Payments screen, so the cashier never adds up paper slips. Each row shows the total, the insurance share, the patient share and the amount collected, so the cashier knows at once what is still owed.

This addresses a familiar slip in hand-run clinics: a patient gets an extra test but the slip never reaches the cashier and it goes unbilled. When the order and the money live in one record, any order that exists has its charge.

Compared with paper slips, the difference is that the order, the result, the attachments and the cost all belong to one visit. Doctors, nurses and cashiers share one record, so nothing is recopied between steps, and whoever opens a follow-up chart finds earlier diagnostics in the visit history.

This page does not describe receiving results automatically from lab analyzers or a dedicated image archive, because we have no published documentation of that. If your clinic needs it, raise it specifically in a demo so you get an answer based on the real product rather than a vague promise. The main users of this area are ordering doctors, nurses, staff entering results and cashiers.