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Doctor Consultation in CCMS

What a consultation can do

Beyond writing the clinical note, the doctor can — from within the same screen — auto-allocate the patient to procedure or emergency units, order lab and radiology investigations, book follow-up appointments, and refer to internal special services via Hub Refer & Register. No paper forms, no separate logins.

Scope

This page covers everything a doctor can do during a CCMS consultation. Picks up where the Patient Registration Workflow ends — patient is seated in the consultation room with vitals already captured. Applies to consultation units OPD, NCD, KKIA, and downstream Procedure Room.


1. Writing the consultation note

Two complementary modes — most consultations use a mix of both.

Free-text consultation

Type directly into the consultation note field. Best for:

When free-text fits
  • Atypical or undifferentiated presentation that doesn't match any template
  • Brief acute visits (single complaint, single intervention)
  • Follow-up notes where a structured template was already used at the index visit
  • Documenting conversations, social context, or family discussions

Free text accepts standard formatting (paragraphs, bullet markers, basic markdown). CCMS auto-saves on field blur.

Template-based consultation

Pre-built structured templates auto-populate the note with the right headings, assessments, and clinical-code mappings for the encounter type. Saves typing, improves coding completeness, and ensures the note has an audit-friendly shape.

Common templates available
  • Fever / Acute Febrile Illness — temperature trend, red-flag screen, tropical disease prompt
  • Diabetes Mellitus follow-up — HbA1c trend, foot screen, medication review, lifestyle counselling
  • Hypertension follow-up — multi-visit BP trend, target-organ damage screen, medication titration
  • Acute Respiratory Infection — cough/sputum characterization, antibiotic stewardship prompt
  • Antenatal visit — gestation, fetal movements, BP, urine dipstick, fundal height
  • Wound assessment — wound type, dimensions, exudate, dressing plan

2. Auto-allocation to other units

The doctor can transfer the patient to another unit in 1-2 click. CCMS updates the patient's location, notifies the receiving unit's and routes the queue automatically — the encounter entry & consultation note travels with the patient.

Procedure room

Routine

Click Allocate → Procedure for wound dressing, suturing, joint injection, ear syringing, IM/IV administration, or any minor procedure. The procedure room nurse sees the patient appear in their queue with the linked consultation note open.

Emergency referral

Critical

Click Allocate → Emergency for any patient needing hospital-level care. Referral letter can then be generated from the consultation note, attaches recent vitals and lab results & other relevent findings. Standard MOH referral templates apply per category (medical, surgical, O&G, paediatric, mental health).


3. Lab and radiology orders

Order investigations directly from the Clinical Tree via the Investigations panel:

What can be ordered
  • Lab tests — FBC, RP, LFT, lipid profile, HbA1c, urine dipstick + full report, microbiology cultures, etc. Searchable, with department-specific routing
  • Imaging — CXR, abdominal X-ray, USG abdomen/pelvis, ECG (clinic-side); CT / MRI handled as outbound referral
  • POCT — point-of-care tests where the clinic supports them (random glucose, urine pregnancy, rapid antigen)

Order status flows back to the patient's rota as results arrive — pending tests show as yellow, completed as green with the result inline.


4. Follow-up appointments

Book the patient's next visit before they leave the room.

  • Date + time slot picker — checks the available schedule and the unit's capacity
  • Reason for visit: further details can be written
  • Recurrence option — for chronic disease follow-ups, recalls can be use for additional monitoring services
  • Reminder preference — reminder can be set in patient's profile for any important and crucial information.

Appointments appear in the patient's record, the unit's rota schedule, and the appointment ledger for clinic admin.


5. Hub Refer & Register — Internal Special Services

CCMS provides a built-in referral pathway for special services hosted at the same facility or across networked facilities. The Hub Refer & Register module routes the patient to the receiving service with the consultation context attached — no paper, no re-registration at the receiving end.

Special services available via Hub
  • Mental Health Clinic — psychiatric assessment, counselling
  • Medication Review — DMTAC, Respi-MTAC, RVD-MTAC by pharmacist
  • TB Clinic — DOTS supervision, contact tracing
  • HIV / STI Clinic — testing, treatment, partner notification
  • Methadone Clinic — MOT enrolment, daily dispensing
  • Dietitian — NCD nutrition counselling, weight management
  • Physiotherapy — musculoskeletal, post-stroke rehab
  • Quit Smoking Clinic — nicotine replacement therapy, behavioural support

The receiving service sees the new referral in their queue immediately. The doctor's consultation note and any pending investigations carry across — the special-service clinician picks up the same patient record without duplicate entry.


Capabilities at a glance

WHAT THE PATIENT'S SCREEN ENABLES
Document
Free-text + structured templates for fever, DM, HTN, antenatal, wound care
Allocate
Procedure room or emergency referral — one-click transfer with notes attached
Investigate
Lab + imaging orders inline with urgency tagging; results auto-attach
Schedule
Follow-up appointments with recurrence + SMS/WhatsApp reminders
Refer
Hub Refer & Register — MH, TB, HIV, dietitian, physio, quit-smoking

Contributor

FJ

Dr Fuad Jaafar

Facilitator, CCMS • KK Bandar Maharani

84 contributions

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Page info

Reviewed May 2026
Next review Nov 2026
Dr Fuad Jaafar

Sources

  1. MOH: Garis Panduan Konsultasi Pesakit Luar

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