Clinical Sessions & Notes

Opening a session

A session is the clinical record for a single appointment.

To open a session:

1. From the Calendar or Waiting Room, click an appointment with status IN_CHAIR.
2. Click Open Session — the session panel opens.

The session auto-saves a draft to the browser every keystroke. If you close the tab by accident, re-opening the session restores your draft.

Session tabs

Each session has multiple tabs. The tabs visible depend on your clinic specialty:

Notes — All specialties (SOAP format)

Vitals — All specialties (BP, HR, temp, SpO2, weight, height)

Prescription — All specialties

Services — All specialties (procedures billed this session)

Tooth Chart — Dental only

Eye Exam — Optical only

Pediatrics — Pediatrics only

Dermatology — Dermatology only

Cardiology — Cardiology only

Physiotherapy — Physiotherapy only

SOAP Note — General Medicine

Post-Op — Surgical specialties

Tabs not relevant to your clinic type are hidden entirely.

Recording vitals

In the Vitals tab, record:

Blood Pressure (mmHg — Systolic / Diastolic)

Heart Rate (bpm)

Temperature (degrees C)

SpO2 (%)

Weight (kg — triggers BMI calculation if height is set)

Height (cm — stored once, reused across sessions)

RBS / FBS (mmol/L — optional, shown for diabetic patients)

Vitals are stored per-session and plotted as trend charts on the patient profile.

Writing a prescription

In the Rx tab:

1. Click + Add Medication.
2. Search the medicine catalogue (200+ pre-loaded drugs, or add custom).
3. Set dosage, form, frequency, duration, and route.
4. Clinit runs an automatic drug-interaction check against all other medications in the session and the patient active medication list.
5. Interaction warnings appear immediately — yellow (caution) or red (contraindicated).

Prescriptions can be printed on clinic letterhead or sent to the patient via WhatsApp as a PDF.

Saving a session

When you are done:

1. Click Save & Complete Session.
2. Clinit automatically:

- Marks the appointment as COMPLETED

- Creates a draft invoice with all services from the Services tab

- Updates the patient lastVisitAt timestamp

- Saves the session notes, vitals, and prescription permanently

The draft invoice opens immediately so you can review line items, add a discount, or send it to the patient.

Once saved, session notes are read-only. Admin-role users can unlock a session for editing if a correction is needed.

AI copilot during sessions

Three AI actions are available from within any open session:

1. CLINICAL SUMMARY (AI)

Available after vitals and notes are entered.

Click: Session > AI > Generate Clinical Summary.

Output: A structured 150-word summary of the session covering chief complaint, relevant history, examination findings, assessment, and plan. Formatted for the patient portal and printed visit summaries.

1. SMART PRESCRIPTION REVIEW (AI)

Triggered automatically when the session is saved with medications in the Rx tab.

Also available manually: Rx tab > Review All Prescriptions.

Checks: drug interactions, dose ranges, contraindications, pregnancy/renal flags.

Output: colour-coded result (green/amber/red) per medication with plain-language explanation.

1. REFERRAL LETTER (AI)

Session > Print > Referral Letter > AI Generate.

Input: select the target specialty (Cardiology, Dermatology, ENT, etc.).

The AI auto-populates the referral with: patient demographics, reason for referral, relevant history from the medical record, current medications, and the last 3 lab results. Specialty-specific data is added automatically (e.g. last ECG result for Cardiology, body map and PASI score for Dermatology).

The letter is print-ready in PDF format and can be sent to the patient portal for them to share with the specialist.