Possible conditions, your decision and signing

Once the safety check has cleared — or an escalation has been documented — the encounter moves on to assessment.

Possible conditions

Select Show possible conditions. The system lists up to five conditions the recorded findings could point to, most likely first. Each one shows:

• a confidence label — High, Moderate or Low,
• the findings that support it (marked +), and
• the findings that call for caution (marked −).

For example, a cough for three days with no fever and no breathlessness lists Viral upper respiratory infection with high confidence, and shows exactly which three findings supported it.

How to read confidence

Confidence is how many of the rules agree — supporting findings minus cautions. It is not a probability and it is not a diagnosis. A high-confidence label means the pattern fits well; it never means the patient has that condition.

What to keep in mind

• These are suggestions to think with. You decide.
• The list comes from a starter set of common patterns (chest and throat symptoms, headaches, urinary and stomach complaints, skin reactions and muscle pain). If nothing matches, the list is empty — that does not mean nothing is wrong.
• It is rule-based, not artificial intelligence. Nothing is sent anywhere.
• If your workspace has turned on AI clinical assistance, an additional Clinical Reasoning and Management Considerations panel appears here too, always alongside — never instead of — this list. See AI clinical reasoning.

Your decision

This is the part only you can do. In Your decision, choose what you decided to do:

• Manage: Self-care / lifestyle advice, OTC treatment, Pharmacy-managed condition, Medication-related intervention, Chronic-disease intervention.
• Refer: Refer to physician, Same-day medical review, Emergency referral.
• Other: Follow-up required.

Add notes on what you advised, supplied or arranged, and why. The safety check's advice is shown above the choices when it advised a referral.

Recording conditions

Under Conditions to record, tick any suggestion worth keeping and choose how to record it — Confirmed, Possible condition or Clinical consideration. You can also add your own condition by name. These become entries on the patient's diagnoses — see Diagnoses. Recording none is fine.

Medication safety and other steps

Three steps of a full clinical workflow are shown as "Lands in Phase …" cards: the medication safety check, condition-specific chronic-disease workflows, and tracked interventions. They are not built yet. Until they are, check medicines against the patient's allergies and other medicines yourself.

Follow-up

Tick A follow-up is needed, choose the due date and say what to check. A real follow-up task is created for the patient, in Follow-ups, linked back to this encounter.

Select Record decision.

Review the note and sign

The system drafts a SOAP note from the encounter — what the patient presented with, the vitals, the triage result and possible conditions, and your decision. It is shown in editable boxes. Change anything you like, then select Sign and close.

Signing:

• saves the note to the patient's Clinical Notes (type Consultation, linked to this encounter),
• closes the encounter — a signed encounter can't be reopened or cancelled.

If the note can't be saved for some reason, the encounter stays open so you can fix the text and try again. Signing twice by accident (a double click) still produces only one note.

If your workspace has AI clinical assistance on, an Improve with AI button appears next to the draft, to rewrite it into cleaner prose without adding anything new, and a Counselling Points (AI) card offers spoken points to relay to the patient — see AI clinical reasoning. You still edit and sign it yourself either way.

Cancelling an encounter

Use Cancel encounter at any point before signing. A reason is required. Nothing is deleted — the encounter stays on the record marked Cancelled.

Related

• AI clinical reasoning
• Diagnoses
• Writing a clinical note
• Follow-ups