The internal medicine visit — from complaint to plan, in one chart.

The visit has six sections: complaint, history, vital signs, general examination, diagnosis and plan. Every section also has a free-text field, so doctors can write the way they are used to.

• History: past illnesses and operations, family history, risk factors (hypertension, diabetes, dyslipidaemia, obesity, chronic kidney disease), smoking and pack-years, alcohol, physical activity, vaccinations, current medicines and allergies
• General examination: general condition, consciousness, nutrition, oedema, skin and mucous membranes, lymph nodes, head and neck, respiratory, cardiovascular, abdomen, genitourinary, musculoskeletal and a neurological screen; a normal exam fills in with one click
• Vital signs: blood pressure, heart rate, respiratory rate, temperature, SpO₂, pain score; body mass index is calculated automatically from weight and height
• Diagnosis with an ICD-10 code; a visit can't be completed without complaint and diagnosis. The plan records investigations, referrals, recommended vaccinations, risk-factor changes (stopping smoking, diet, exercise, a weight target) and sick leave
• Doctors' own templates and one-click copy from the previous visit; visit summaries and referral letters as PDFs

Scales are scored during the visit and saved to the patient's chart; each scale's results are plotted. CURB-65 grades pneumonia severity, McIsaac (the modified Centor score) the likelihood of strep in a sore throat, and FINDRISC the risk of type 2 diabetes. Blood pressure, heart rate and body mass index measured at visits are plotted on the patient's chart too.

If your clinic switches it on, the patient is invited 72 hours ahead to fill in an internal medicine questionnaire in the portal — about 5 minutes: the complaint and how long it has lasted, symptoms, past illnesses, family history, vaccinations, medicines, allergies and lifestyle. If the patient reports chest pain right now, severe breathlessness at rest, or confusion and a stiff neck with a high temperature, the portal tells them straight away to call 112. Nobody reads the questionnaire before the visit — the doctor sees the answers during the visit and moves them into complaint and history in one click; what the doctor wrote is never overwritten.

When the visit is completed, the doctor shares a plan with the patient: the follow-up date, tasks and warning signs. There are ready-made lists for chest infection and pneumonia, urinary tract infection, and stomach pain, vomiting and diarrhoea, so the patient gets in writing when to call 112 and when to contact the clinic. At the doctor's request the patient keeps a blood-pressure, blood-glucose or weight diary in the portal and decides whether to share it with your clinic; shared readings appear in the "Home data" tab. With medication reminders the patient logs doses taken and skipped, and the doctor sees this on the chart for medicines your clinic prescribed. Nobody watches any of this in real time — the doctor reviews it at the visit.

With hypertension, diabetes and other chronic conditions, regular check-ups are a large share of revenue. Unbooked follow-ups land on a recall list, and a freed slot is offered to the waitlist. Cash-desk shifts, discount limits, voluntary insurance registries and doctor commissions live in the same system. Allergies and drug interactions are checked automatically when a prescription is written — including what other clinics prescribed.