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Platform module
Clinical Encounters, Admissions & Discharge
Consultations, ward rounds, admissions and discharge in a record that keeps its history instead of being overwritten.
What it is
A clinical note is a legal document. GSHS treats it as one: an encounter can be completed, but never quietly edited afterwards. Corrections are addenda, attributed and time-stamped, so the sequence of clinical reasoning survives.
Admissions carry the same discipline through to discharge, including a medication reconciliation step the clinician must work through before the discharge can be completed.
Active encounter
General consultation · Room 4
Vitals
BP
118/76
Pulse
72 bpm
Temp
36.7°
SpO₂
98%
Full blood count verified now
New since last visitConsultation note
Why teams value it
Structured vitals
Captured consistently so they can be trended.
Hard allergy block
A conflicting prescription cannot be saved.
Addenda only
Completed notes are corrected, not rewritten.
Live ward view
Current admissions grouped by ward, from live data.
One screen for the whole consultation
Vitals, notes, diagnosis coding, prescribing and ordering all happen in the encounter. Everything written there is attributed to the authoring clinician and stamped with the department and branch.
- In progress / completed / amended states
- Diagnosis coding from a shared code list
- Lab and imaging ordered without leaving the note
The check that actually stops the save
Before a prescription is written, GSHS re-reads the patient's active allergies from the database — never a cached copy in the browser — and refuses to save a conflicting medicine. Where a clinician deliberately overrides, the reason is stored with the prescription.
- Live database check on every prescription
- Cross-reaction classes, not just exact drug names
- Override reasons retained for review
Know who is in which bed right now
Admission records the clinical indication, ward and bed. The ward occupancy view is built from live admissions, so the bed list on screen is the bed list on the floor.
- Ward and bed assignment with release times
- Inpatient days charged on discharge
- Occupancy grouped by ward
Medication reconciliation before the patient leaves
Discharge asks for the summary and discharge diagnosis, and requires the clinician to review the patient's active medication list on the same screen before the discharge can be completed.
- Discharge summary and coded diagnosis
- Explicit medication review step
- Discharge time recorded automatically
Questions about this module
Explore related modules
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Read moreLaboratory & Imaging
Orders, specimens, results and a separate verification step, with turnaround measured rather than estimated.
Read morePrescriptions, Pharmacy & Public Verification
Safe prescribing, real stock control, and a printable prescription anyone can verify as genuine.
Read moreSee this module on real screens
Book a walkthrough and we will demonstrate it using workflows that match your facility.