Acute Care Playbook

This playbook explains how doctors use EMR features—such as diagnostic coding tools, AI assistance, pre-packaged prescription bundles, and document templates—to chart and prescribe treatments for common Acute Conditions (e.g., Upper Respiratory Tract Infection (URTI), Gastroenteritis, and Urinary Tract Infections (UTI)).

Detailed Step-by-Step Walkthrough

Step 1: SOAP Macros & Note Templates

To minimize typing and standardize charting during acute consultations:

1. In the open EMR SOAP editor, navigate to the Clinical Notes section (clinical-notes.vue).
2. Click Apply Template to open the note templates library (clinical-note-template-slideover.vue).
3. Select the template for your condition (e.g., Common Cold / URTI):
   • Subjective: Auto-fills typical acute symptoms (e.g., cough, sore throat, fever duration).
   • Objective: Auto-fills physical examination defaults (e.g., chest clear, throat mildly injected, abdomen soft).
4. Customize the text by adding specific patient details or deleting irrelevant sections.

Step 2: Diagnostic Search & ICD-11 Coding

To ensure accurate clinical data entry and billing codes:

1. Scroll to the Diagnosis component (diagnosis.vue).
2. Click the diagnosis search bar. This interface integrates the official WHO ICD-11 tool via the @whoicd/icd11ect library.
3. Type the condition (e.g., "Gastroenteritis" or "Infectious Gastroenteritis").
4. The system queries the database and ICD-11 API:
   • Select the matching ICD-11 term.
   • The system automatically binds the selected ICD-11 code (e.g., 1A40.0 for Viral Gastroenteritis) to the active encounter.

Step 3: Prescribing Pre-Bundled Medication Packs

Instead of selecting medications individually, prescribe complete treatment packages in one click:

1. In the EMR toolbar, click Prescribe Bundles under Prescriptions (prescriptions.vue).
2. Search for the pre-configured Cold & Flu Medication Pack (managed in Settings /settings/prescription/prescription-packages using prescription-template-object-layout.vue):
   • Paracetamol (Panadol) 500mg (Qty: 20 tablets, Dose: 1-2 tabs QDS PRN)
   • Chlorpheniramine 4mg (Qty: 10 tablets, Dose: 1 tab ON)
   • Decongestant Syrup (Qty: 1 bottle, Dose: 10ml TDS)
3. Click Apply Bundle to add all items to the active prescription list.
4. AI Clinical Assistant Validation:
   • The AI Clinical Assistant (clinical-assistant.vue / clinical-assistant-medication-card.vue) monitors entries in real-time.
   • It runs cross-checks against the patient's active allergies, age, and existing medications, displaying a warning banner if any potential drug-drug interactions or clinical contraindications are detected.

Step 4: Generating a 1-day Digital MC

1. Scroll to the Medical Certificate section (medical-certificate.vue).
2. Click Create MC to open the certificate generator.
3. The system defaults the start date to today. Select a duration of 1 day.
4. The system automatically retrieves the diagnostic description from the ICD-11 code bound in Step 2.
5. Click Apply Signature & Generate.
   • Verification QR Code: The system prints a cryptographically signed PDF containing a verification QR code, making it instantly verifiable by employers.