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How to record a consultation (SystmOne)

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Written by Youmei

This guide covers: how to code a problem, how to link a consultation to an existing problem, how to code multiple problems, and how to discard a consultation.

Patient Selection

1. Retrieve the patient.

Consultation Initialization

2. Click Start Consultation.

Recording Clinical Findings

3. The consultation will appear in blue — fill out the fields as necessary, coding where possible.

4. Always select the most accurate and precise diagnosis from the available clinical codes — do not use free text.

History: write the patient's presenting complaint and history of presenting complaint.

5. Change the consultation type (e.g. F2F → Telephone) by clicking Event Details and changing Contact Method.

⚠️ Every Asterix Doctor Consultation should include:

  • 👩‍💼 3-point ID check: name, DOB and address at start of call

  • Presenting complaint in the patient's words and relevant history with pertinent negatives (red flags 🚩)

  • Your clinical reasoning — not just a diagnosis

  • The plan and necessary follow-up — specific, not vague

  • Safety-netting — written out explicitly

How to add a second problem

6. Select New Section to document a second clinical issue and its management strategy.

How to Link a Consultation to an Existing Problem/Diagnosis

7. Optional: Link consultations to existing conditions by clicking on the green Problems Flag.

Finishing the Consultation

8. Click Save to save and close the patient record (top toolbar).

⚠️ If you do not click save, all your consultation notes will be lost!

Example of a consultation

9. Here is an example of a completed consultation — showing the three-point ID check, coded information in green, coded diagnosis, and safety netting.

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