Consultation notes and vitals
Record chief complaint, vitals (BP, pulse, temperature, weight, SpO2), examination findings and diagnosis for each OPD visit, on the patient's record.
Each visit opens with the chief complaint, usually taken at the front desk or by an assistant before the patient goes in. Vitals sit alongside it: blood pressure, pulse, temperature, weight and SpO2, entered by whoever measures them.
The doctor adds examination findings, the diagnosis and any notes. Everything is saved against that visit, so the next time the patient comes the previous readings are one glance away and a trend in BP or weight is visible without hunting.
Notes are the doctor's words. Clinicket records them; it does not suggest a diagnosis or a treatment, and every clinical decision stays with the treating doctor.