Doctor Consultation in CCMS
Beyond writing the clinical note, the doctor can — from within the same screen — auto-allocate the patient to procedure or emergency units, order lab and radiology investigations, book follow-up appointments, and refer to internal special services via Hub Refer & Register. No paper forms, no separate logins.
Scope
This page covers everything a doctor can do during a CCMS consultation. Picks up where the Patient Registration Workflow ends — patient is seated in the consultation room with vitals already captured. Applies to consultation units OPD, NCD, KKIA, and downstream Procedure Room.
1. Writing the consultation note
Two complementary modes — most consultations use a mix of both.
Free-text consultation
Type directly into the consultation note field. Best for:
- Atypical or undifferentiated presentation that doesn't match any template
- Brief acute visits (single complaint, single intervention)
- Follow-up notes where a structured template was already used at the index visit
- Documenting conversations, social context, or family discussions
Free text accepts standard formatting (paragraphs, bullet markers, basic markdown). CCMS auto-saves on field blur.
Template-based consultation
Pre-built structured templates auto-populate the note with the right headings, assessments, and clinical-code mappings for the encounter type. Saves typing, improves coding completeness, and ensures the note has an audit-friendly shape.
- Fever / Acute Febrile Illness — temperature trend, red-flag screen, tropical disease prompt
- Diabetes Mellitus follow-up — HbA1c trend, foot screen, medication review, lifestyle counselling
- Hypertension follow-up — multi-visit BP trend, target-organ damage screen, medication titration
- Acute Respiratory Infection — cough/sputum characterization, antibiotic stewardship prompt
- Antenatal visit — gestation, fetal movements, BP, urine dipstick, fundal height
- Wound assessment — wound type, dimensions, exudate, dressing plan
Pick the template from the dropdown at the top of the consultation screen. Templates compose with free text — fill the structured fields, then add free-text remarks below as needed.
Leave unused template fields empty rather than deleting the headings. Future readers and auditors look for the structured shape; removing it makes the note appear incomplete even when clinical care was complete.
2. Auto-allocation to other units
The doctor can transfer the patient to another unit in one click. CCMS updates the patient's location, notifies the receiving unit's nurse, and routes the queue automatically — the consultation note travels with the patient.
Procedure room
Click Allocate → Procedure for wound dressing, suturing, joint injection, ear syringing, IM/IV administration, or any minor procedure. The procedure room nurse sees the patient appear in their queue with the linked consultation note open.
Emergency referral
Click Allocate → Emergency Referral for any patient needing hospital-level care. CCMS auto-generates the referral letter from the consultation note, attaches recent vitals and lab results, and updates the patient status to "Awaiting transfer." Standard MOH referral templates apply per category (medical, surgical, O&G, paediatric, mental health).
3. Lab and radiology orders
Order investigations directly from the consultation note via the Investigations panel — no separate form, no paper request.
- Lab tests — FBC, RP, LFT, lipid profile, HbA1c, urine dipstick + full report, microbiology cultures, etc. Searchable, with department-specific routing
- Imaging — CXR, abdominal X-ray, USG abdomen/pelvis, ECG (clinic-side); CT / MRI handled as outbound referral
- POCT — point-of-care tests where the clinic supports them (random glucose, urine pregnancy, rapid antigen)
Order status flows back to the consultation note as results arrive — pending tests show as amber, completed as green with the result inline.
Every investigation request needs an urgency tag: routine (≤7 days), urgent (≤24h), or stat (immediate, called through to lab). Untagged orders default to routine — set urgency explicitly when timing matters.
4. Follow-up appointments
Book the patient's next visit before they leave the room.
- Date + time slot picker — checks the doctor's schedule and the unit's capacity
- Reason for visit auto-pulls from the current consultation diagnosis
- Recurrence option — for chronic disease follow-ups (e.g. NCD every 3 months); creates the next N appointments at the chosen interval
- Reminder preference — SMS / WhatsApp / no reminder
Appointments appear in the patient's record, the unit's daily schedule, and the appointment editor for clinic admin.
5. Hub Refer & Register — internal special services
CCMS provides a built-in referral pathway for special services hosted at the same facility or across networked facilities. The Hub Refer & Register module routes the patient to the receiving service with the consultation context attached — no paper, no re-registration at the receiving end.
- Mental Health Clinic — psychiatric assessment, counselling
- TB Clinic — DOTS supervision, contact tracing
- HIV / STI Clinic — testing, treatment, partner notification
- Methadone Clinic — MOT enrolment, daily dispensing
- Dietitian — NCD nutrition counselling, weight management
- Physiotherapy — musculoskeletal, post-stroke rehab
- Quit Smoking Clinic — nicotine replacement therapy, behavioural support
The receiving service sees the new referral in their queue immediately. The doctor's consultation note and any pending investigations carry across — the special-service clinician picks up the same patient record without duplicate entry.
Capabilities at a glance
Contributor
Dr Fuad Jaafar
Facilitator, CCMS • KK Bandar Maharani