This guide is designed to help new providers get started with running consultations in MediRecords. It provides a high-level walkthrough of the end-to-end consultation workflow, from taking a patient out of the waiting room, through documenting the consult, and finishing the appointment at the end.

Rather than covering every feature in depth, this article acts as a central starting point, introducing the key tools and workflows you’ll use during a consultation and linking out to more detailed guides where helpful. Use it to build confidence with the clinical record, understand what’s available to you during a consult, and know where to go next when you want to explore specific features in more detail.

Contents

1. Starting the Consultation

   • From the Waiting Room

   • From the Appointment Calendar

2. Reviewing Past Medical History

   • Past Consultations

   • Expanded Clinical View

   • Evolve AI Patient Summary

   • Reviewing Specific Clinical Records

   • Accessing & Uploading to My Health Record

3. Adding Consultation Notes

   • Adding Consultation Notes

   • Selecting a Consult Type

   • Adding a Reason for Visit & Diagnosis

   • Consultation Duration Timer

   • Templating Consult Notes with Shortcuts

   • Uploading an Attachment to a Consultation

4. Adding Clinical Records to a Consultation

   • Recording Allergies & Adverse Reactions

   • Writing Prescriptions & Managing Medications

   • Adding Observations & Vitals

   • Adding Conditions to the Medical History

   • Generating Pathology & Radiology Requests

   • Completing Examinations, Assessments, and Reviews using Templates

   • Writing Letters, Medical Certificates, & Creating Documents

   • Creating Immunisation Records & Reviewing Immunisation History

   • Adding Cases for Case Management

   • Creating Diagrams & Annotated Drawings

   • Recording Antenatal Consults & Pregnancy Information

   • Creating a Cervical Screening Result

   • Creating Procedures

   • Recording Past Admission History

5. Finalising the Consultation

   • Finishing the Consult

   • Sending Billing Items to Reception

Starting the Consultation 

From the Waiting Room

Once the patient has arrived in the clinic and been checked into the Waiting Room, you can start the consultation directly from the Waiting Room. On the side-navigation, click Waiting Room. The patients listed in the With Doctor column have been checked in to the clinic, and are waiting for the start of the consultation.

To start the consultation, click on the patient's name in the With Doctor column, and click Open. You will be taken into the patient's clinical record to begin the consultation.

For more information on the Waiting Room, please see Waiting Room.

From the Appointment Calendar

You can also begin a patient's consult via the Appointment Calendar. To do this, click on the patient's Appointment, then open the More menu, and click Open Patient. 

Reviewing Past Medical History

There are several methods for catching up on a patient record prior to their next consultation.

Past Consultations

A list of all consultations can be found in the Past Consultations tab of the patient clinical record. Clicking Preview allows you to view multiple notes in quick succession, including their time, date, provider, and Reason for Visit.

Expanded Clinical View

The Expanded Clinical View offers you a mechanism for reviewing the recent clinical events that have occurred on  a patient's record, such as letters sent, recalls generated and their status, current medications, past consultations and more. Click the Expand Clinical View option in the Today's Notes tab to review the record in a summary per record type.

For extended information, please see Expanded Clinical View.

Evolve AI Patient Summary

The Evolve AI Patient Summary is a powerful tool designed to support healthcare providers by delivering a concise, AI-generated overview of a patient’s recent activity. It compiles key details from recent consultations, communications, and investigations into a single, easy-to-read page, with quick navigation options between information in the patient record.

This streamlined summary enables providers to quickly refresh their memory before a consultation, improving clinical efficiency and continuity of care. Additionally, shortcut links are included to provide immediate access to full patient records for deeper insights when needed.

Evolve AI Patient Summary is an optional Add-On.

Reviewing Specific Clinical Records

If you are interested in reviewing a specific section of the clinical record, such as the patient's current medications, you can review these sections individually by clicking on the tabs in the Clinical Record, such as Medications. You will then be able to review the specific section for any recent or historical records.

Accessing & Uploading to My Health Record

My Health Record (MHR) is Australia’s national digital health system, designed to give healthcare providers secure access to their patients’ health information. MediRecords integrates directly with My Health Record, allowing you to view key clinical documents, create and upload summaries, and access important patient data such as prescriptions, pathology results, and diagnostic imaging.

For more information on MHR, please see My Health Record (MHR): Quick Guide.

Adding Consultation Notes

Consultation notes are written into the Today's Notes tab of the patient clinical record. 

Selecting a Consult Type

The Consult Type is loaded based on your preferences for your Default Consult Type. Selecting a Consult Type per consultation allows you to later report on the types of consultations you are holding, and other valuable insights. If the consult type selected for you by default is not the most common consult you would hold, you may wish to update your Preferences. Instructions for this can be found in Today's Notes: Preferences & Quick Guide.

Adding a Reason for Visit & Diagnosis

Reason for Visit

When you start the consultation, you may wish to record the reason why the patient has attended today using the Reason for Visit feature. Click the Reason button within the Today's Notes area, and search and select from the SNOMED coded Condition list. If you would like this Reason for Visit to form a permanent part of the patient's file, then we would recommend changing the Add to PMH toggle to Yes.

When adding a Condition, you can use free-text, or select from the SNOMED coded Findings list. We would strongly recommend selecting from the supplied list, as this coding allows Interactions to generate when prescribing, and powers several clinical reporting tools. Free-text entered Conditions will not generate Interactions, or properly contribute to reports on condition spread across patients. 

If the patient has seen you about this Condition in the past, you can change the Existing Condition slider to Yes, and select from the Condition list from the patient to add more information.

More information on Conditions can be found in Medical History & Condition Management: Quick Guide.

Diagnosis

At the closure of the consultation, you may wish to record the formal diagnosis for the patient. To do this, click the Diagnosis button in the Today's Notes area, and search and select from the SNOMED coded Condition list. By default, this Diagnosis will be added to the patient's permanent medical record. If you don't want to do this, change the Add to PMH toggle to No.

If the patient has seen you about this Condition in the past, you can change the Existing Condition slider to Yes, and select from the Condition list from the patient to add more information.

More information on Conditions can be found in Medical History & Condition Management: Quick Guide.

Consultation Duration Timer

Once you have opened the clinical record, the consultation timer will either automatically begin counting, or you will need to click the Start button for the timer. This is a personal preference. If you would like to change whether the counter is automatic or manual, instructions can be found in Today's Notes: Preferences & Quick Guide.

Templating Consult Notes with Shortcuts

You can create Shortcuts which act as templates for consult notes, to help you quickly structure the information in a consistent way across patients and minimise typing effort. For information on creating Shortcuts, please see Today's Notes Shortcuts: Creating & Managing Templated Consult Notes.

Dictating Consult Notes with Heidi AI Scribe

If you would like to avoid typing during consultations, Heidi AI offer an AI powered transcription service, which will translate your spoken word into consultation notes within Heidi and MediRecords. This is a paid service. If you are interested in learning more about Heidi, please see Heidi AI Scribe: Configuration & Quick Guide.

Uploading an Attachment to a Consultation

Attachments allow you to store and manage supporting files directly within a patient’s clinical record, and against a particular consultation record. This includes documents, images, and other files provided by patients or received from external sources. Attachments are securely saved against the record, clearly visible across consultations, and can be accessed whenever needed. You can upload files during a consultation, review previously added attachments, and (with the appropriate permissions) remove files that are no longer required.

For more information on Attachments, please see Attachments: Quick Guide.

Adding Clinical Records to a Consultation

There are a lot of clinical tools available to you in a consultation. The below list is intended to be complete, but not all of the items in this list may be relevant to the care you provide.

Recording Allergies & Adverse Reactions

Allergies & Reactions can be added in via the Allergies pill within the patient header, or via opening the Allergies & Reactions tab and clicking New Allergy. Allergies and Reactions are SNOMED coded when selecting an option from the pre-supplied list, and this information is then used when presenting Interactions during the prescribing workflow. We would always recommend selecting from the SNOMED list rather than free-typing an allergy, so the Interactions service can work on your behalf.

For more information on Allergies & Reactions, please see Allergies & Reactions: Quick Guide.

If you'd like to read more on the scope of the Interactions service, please see Medications: MediSpan Clinical Decision Support & Interactions Service.

Writing Prescriptions & Managing Medications

The management and writing of prescriptions can be complex. We have prepared many helpful documents to support you in prescribing with MediRecords.

Writing Prescriptions

For general information on writing prescriptions, you may wish to read Writing Prescriptions: Quick Guide. We also have articles covering specific scenarios such as writing authority prescriptions. Please see below a list of supporting resources for prescribing medications:

• Authority & Streamlined Prescriptions, & State-Based Authorised Reference Numbers
• Prescribing Schedule 8 (S8) Monitored Medications
• PBS/RPBS Prescriptions: Quick Guide
• Medications: Current & Past RX, and Managing Prescriptions

Real-Time Prescription Monitoring 

If you prescribe monitored medicines such as Schedule 8 prescriptions, as a provider you are bound by legislation to use Real-Time Prescription Monitoring to reduce doctor shopping. MediRecords supports all state-specific portals for monitoring medicines. 

For more information on Real-Time Prescription Monitoring and how to enable the service, please see Real-Time Prescription Monitoring (RTPM): Configuration & Quick Guide

Medispan Interactions Service & Clinical Decision Support (CDS)

The Medispan Interactions Service will display in the prescribing window when there is an expected interaction between the medication being prescribed, and the patient's allergies, medical conditions, age, and more. The full scope of the Interactions service can be seen in Medications: MediSpan Clinical Decision Support & Interactions Service.

Adding Observations & Vitals

Vitals can be added for patients either directly through the Today's Notes tab using the Observation menu, or via the Observations tab using the Add Observation button. Observations can be graphed over time via the Observations grid, using the View options. For more information on Observations & Vitals, please see Observations & Vitals: Quick Guide.

Adding Conditions to the Medical History

Conditions can be added to a patient's medical record via multiple pathways:

• Adding a Reason for Visit in the consultation, and changing the Add to PMH option to Yes
• Adding a Diagnosis to a consultation
• Adding a Condition via the New Condition button in the Medical History tab

When adding a Condition, you can use free-text, or select from the SNOMED coded Findings list. We would strongly recommend selecting from the supplied list, as this coding allows Interactions to generate when prescribing, and powers several clinical reporting tools. Free-text entered Conditions will not generate Interactions, or properly contribute to reports on condition spread across patients. 

More information on Conditions can be found in Medical History & Condition Management: Quick Guide.

Generating Pathology & Radiology Requests

There are multiple methods for creating Pathology and Radiology Requests, otherwise known as Investigation Requests:

• From the Quick Actions bar, click Request Pathology or Request Radiology
• From the Investigations tab, open the Requests tab, and click New Pathology or New Radiology

For instructions on creating requests, please see Investigation Requests - Pathology & Radiology.

Global Requests

Global Requests provides a tenancy wide view of all pathology and radiology requests, helping practices track what is still outstanding, partially received, or requiring action. By improving oversight across clinicians and locations, it supports continuity of care and reduces the likelihood of clinically significant results being overlooked. This article explains how to enable and use Global Requests, filter and review items efficiently, and update statuses or create clinical actions to close the loop with patients.

Global Requests is an optional Add-On that incurs a price, as part of the MediRecords Premium Features suite.

Completing Examinations, Assessments, and Reviews using Templates

Clinical Templates in MediRecords are designed to save time, improve consistency, and support best-practice care during consultations. These pre-built questionnaires cover a wide range of common clinical scenarios, from general examinations to specialised assessments such as cardiovascular, musculoskeletal, mental health, and more. By using templates, providers can capture structured information quickly and ensure nothing important is missed.

To read more on Clinical Templates, please see Clinical Templates: Examinations, Health Assessments, & Reviews.

Writing Letters, Medical Certificates, & Creating Documents

Letters in MediRecords provide a flexible way to create professional correspondence directly within a patient’s record. Whether you need to generate a general letter, a medical certificate, or a specialist referral, MediRecords makes the process quick and seamless. With merge fields that pull patient and practice details automatically, you can save time on manual data entry and ensure that your letters are always accurate and consistent.

For more information on letter writing and documents, please see Letter Writing: Quick Guide.

Creating Immunisation Records & Reviewing Immunisation History

Managing immunisation records is a key part of delivering safe, high-quality patient care. MediRecords provides an efficient way to create, update, and track immunisations directly within the patient record. By recording vaccines, linking recalls, and maintaining accurate schedules, your practice can ensure patients remain up to date with recommended immunisations while meeting national reporting requirements. 

Immunisation records are created directly through the Immunisations tab in the clinical record, by clicking New Immunisation. From here, you can batch and send immunisation records to the Australian Immunisation Register if connected. For more information on Immunisations and AIR, please see Immunisations: Quick Guide and AIR Claiming: Quick Guide.

Vaccinations that have been submitted to AIR by providers outside of your clinic can be viewed via the AIR Immunisation History tab, and any upcoming or overdue doses are displayed.

Adding Cases for Case Management

Case Management in MediRecords is a premium feature designed to give practices a smarter and more structured way to manage chronic health conditions. By creating a Case, you can centralise everything related to a patient’s condition in one place, including consultations, referrals, session tracking and supporting documentation. This makes it easier for your team to collaborate, monitor patient progress and ensure continuity of care across multiple providers.

For practices working with patients who need long term or ongoing management, Case Management is a game changer. 

Case Management is an optional Add-On that incurs a price, as part of the MediRecords Premium Features suite.

Creating Diagrams & Annotated Drawings

Clinical Drawings in MediRecords allow providers to visually document patient findings by drawing directly onto anatomy images or uploaded photos. This is particularly useful for highlighting areas of concern, tracking changes over time, or providing clear illustrations that support clinical notes. Tablet users can also capture photos of patients in real time and annotate them immediately, making this feature practical in a wide range of care settings.

For more information on Clinical Drawings, please see Clinical Drawing Tool: Quick Guide.

Recording Antenatal Consults & Pregnancy Information

Accurate management of pregnancy records is crucial for delivering safe, consistent, and coordinated antenatal care. Within MediRecords, the Current Pregnancy section allows providers to record vital details, track progress, and document results, outcomes, and associated visits. This ensures continuity of care and keeps all pregnancy-related information together in one place. Past Pregnancy information is also stored within the Obstetrics tab. 

For more information on Obstetrics in MediRecords, please see the following guides:

• Obstetrics: Current Pregnancy Records
• Obstetrics: Past Pregnancy Records
• Obstetrics: Antenatal Visits & Consults

Creating a Cervical Screening Result

The Cervical Screening section provides a clear summary of all recorded smears, displaying key details such as dates, results, HPV status, endocervical cell presence, performing doctor, and any clinical comments noted at the time of the procedure. This ensures clinicians have quick access to vital information during follow-up care or when planning future investigations.

For more information on Cervical Screening, please see Cervical Screening: Quick Guide.

Creating Procedures

The Procedures module in MediRecords is designed specifically for specialists, providing a structured way to record, track, and manage clinical procedures within a patient’s record. From admission details through to outcomes, the module ensures all stages of a procedure are captured in one place, helping specialists maintain accurate records while streamlining their workflow. By integrating procedures directly into the clinical record, you can also ensure important information is easily accessible and linked to the consultation notes.

Procedures, Theatre Lists, and the Procedure Detailed Report are only available to users with a Specialist license.

 For more information on the Procedure feature set, please see Procedures & Theatre Lists: Quick Guide.

Recording Past Admission History

Managing a patient’s Admission History in MediRecords helps you keep track of hospital visits, procedures, and treatment details all in one place. By recording and updating admissions directly in the patient’s clinical record, you create a reliable history that supports better decision-making and continuity of care across your practice. Each record captures key information such as admission dates, facilities, length of stay, reasons for admission, and related procedures.

For more information on Admission History, please see Admissions: Admission History.

Finalising the Consultation

Once you have finished recording your notes and adding all the relevant records, you can then proceed into the wrap up stage for your consultation.

Finishing the Consult

The consultation can be finished manually, or by an automatic schedule. If you click the Finish button in the Today's Notes window, the consult timer will stop, and the duration for the consultation will be recorded against the consultation in the Past Consultations tab.

In case you do forget to finish the consultation, the consultation will automatically be closed at midnight on the day of creation. Certain rules will prevent the closure of the consult record at midnight, if the consult were started late at night (to prevent the record from closing while you are writing). More information is available in Today's Notes: Preferences & Quick Guide.

Sending Billing Items to Reception

If Consultation Billing is enabled for your user, when you click Finish on the consultation, you will be presented with a window where you may select the relevant billing items for your admin staff to process on the patient's invoice and claim (if applicable). If you are interested in enabling this option, please see Consultation Billing - Selecting Items to be Billed after a Consult.

Running a consultation in MediRecords is designed to be intuitive, flexible, and supportive of high-quality clinical care. From starting the consult in the Waiting Room or Appointment Calendar, through reviewing the patient’s history, documenting notes, prescribing, ordering investigations, and recording clinical outcomes, MediRecords brings all the essential tools together in one streamlined workflow.

This guide has provided a high-level overview of what’s available to you during a consultation and how the different features fit together. As you become more familiar with the platform, you can explore the linked guides to deepen your understanding of specific tools and tailor your workflow to suit your clinical practice.

Use this article as your foundation, return to it when you need a refresher, and continue building confidence as you make MediRecords your day-to-day clinical workspace.