Medical consultation and prescription

The medical consultation is the record of a visit: the veterinarian sees the pet, notes the reason for the visit, explores it, reaches a diagnosis and, if needed, writes a prescription. In PetSoph each consultation belongs to the pet’s clinical record and can generate one invoice.

Getting there

  1. Clinical → Medical consultation (New consultation from the record of an open pet).

Medical consultation history in clinical record Figure 1. List of recorded medical consultations with diagnosis and prescriptions.

1. Registering the visit

  • Pet and date and time of the consultation.
  • Reason for the visit (reason): in the owner’s words, e.g. “he stopped eating”.
  • Clinical signs / symptoms (symptoms): what the vet observed and the owner reports.
  • Physical exam findings (physicalExam): what the exploration reveals.
  • Working diagnosis (diagnosis): the provisional or definitive diagnosis (choose from the catalog).
  • Observations (observations): free text to complete the record.
  • Photos (up to 3): lesions, masses, rashes… each with optional caption.

New medical consultation dialog Figure 2. Dialog for recording a medical consultation, diagnosis, and prescriptions.

Consejo

The clearer the reason for the visit (as the owner says it) and the clinical signs, the better the follow-up: the next veterinarian reads the same story in seconds.

2. Medical prescription (recipe)

In the same screen, in the Prescription section, you add the medicines:

Field What it is for
Medicine (product) The active product from the pharmacy catalog
Dosage e.g. 1 tablet / 5 kg every 12 hours
Frequency How often per day
Duration Number of days of treatment
Route Oral, topical, injectable…
Parenteral? Mark if it requires dispensing (see below)
Observations Free text (e.g. “with food”)

The prescription is the formal order to the pharmacy: it is what will be dispensed later and what appears on the printable prescription.

Controlled medicines

If the product is a controlled drug, PetSoph requires:

  • The vet has a valid license. Without a license, prescribing that medicine is blocked.
  • The record keeps track of the controlled medicine.
Importante

Prescribing a controlled medicine without a valid veterinarian license is not allowed: the system blocks it immediately and warns you.

Save and bill

  1. Save the consultation (it remains ready to bill).
  2. If you closed the visit already, settle it with the Consolidated check-out to charge consultation + prescriptions in a single invoice.
Nota

A consultation is invoiced only once. To fix the amount, void the invoice from the Cash Register first; it cannot be deleted straight from the record.

What’s next