Solution
BuiltA consultation record a doctor can sign, and correct without overwriting.
Complaints, examination, coded diagnosis, prescription and orders, in one screen, on the chart the front desk already opened.
An electronic medical record is the clinical record one practice keeps about its own patients: the notes, the prescriptions, the results. It is distinct from an EHR, which is designed to be shared between providers.
What a consultation actually captures
Enough to be a real clinical record, and not so much that writing it takes longer than the consultation.
- Chief complaints and examination notes against the visit
- Coded diagnosis using ICD-10-CM
- Prescription with a searchable drug list showing price and stock
- Laboratory orders raised in the consultation and tracked to result
- Vitals, configured per hospital, visible in the chart
- Documents attached to the patient and to the visit
- Clinical pathways for common conditions across 24 specialties, offered as suggestions you tick
- Recorded allergies shown on the prescription, and the exact drug an allergy names flagged
- Dictation into the note in Chrome or Edge, in English and nine Indian languages
- Drug interaction checking(planned)
Signing, and correcting
A signed consultation is closed. When it needs correcting, as it does, the doctor states a reason, the version as signed is preserved, and re-signing records who changed what, when and why, field by field. Reopening a closed record is a separate permission from writing one, so a hospital can let every doctor write freely and still decide who may reopen.
- Sign-off with the doctor's signature image, versioned and pinned to what it signed
- Amendment with a mandatory reason and a field-level change record
- Reopening a signed note is its own permission
- Deleting a consultation, which is not available at any permission level, by design
How it runs
- 01
Open the chart
The patient is already checked in, so the chart opens with the treatment case, past visits, bills and documents in view.
- 02
Write
Complaints, examination, diagnosis. The save state is always visible, and it says whether the note is saved.
- 03
Prescribe and order
Drugs from your catalog with price and stock; tests from your test list. Both post to the pharmacy and laboratory queues.
- 04
Sign
The note closes. If it needs correcting later, that is an amendment with a reason, not an edit.
What this does not do
There is no drug database behind the prescription. The drug list is your hospital’s own catalog, and the software does not check interactions or allergy classes; it flags only the exact drug an allergy names, and dose ceilings exist only in the pediatric dosing helper. Specialty modules exist for twenty-three specialties, each switched on per hospital and built as an independent module rather than a branch in the core; some of their tools are not built yet, such as a dermatology body map, dental radiographs by tooth, a partograph and chemotherapy day care.
Questions we are asked
What is the difference between an EMR and an EHR?
An EMR is one practice’s own clinical record. An EHR is designed to be shared across providers, which in India means ABDM. We have built both sides; the sharing half is not certified.
Can a doctor edit a signed note?
Never in place. A signed note is corrected by amendment: the doctor states a reason, the signed version is preserved, and the change is recorded field by field. That is a deliberate design decision, not a limitation.
Does it work on a tablet?
It is responsive web, so yes. There is no native app, and there will not be one until the web Portal is shown to be insufficient for a specific role.
Are diagnoses coded?
Yes, from a checked list of common ICD-10-CM codes. SNOMED CT and ICD-11 are planned scope.
Other solutions
What a Hospital Management System (HMS) Covers
BuiltOne platform for patients, appointments, OPD, the consultation record, pharmacy, laboratory and billing, with tenant isolation enforced in the database and every module a switch your hospital actually controls.
Clinic Management Software for Indian Clinics
BuiltRegistration, queue, consultation, pharmacy, laboratory and the bill, for a clinic that wants one system rather than four that do not speak to each other.
EHR Software Built for ABDM Record Sharing
PlannedABHA identity, care contexts, consent artefacts and FHIR record bundles. Built to Milestones 1 to 4, with ABHA, record sharing and record requests run end to end in the NHA sandbox, and not certified.
Laboratory Management System (LIS) Software in India
BuiltA test catalog you control, orders raised in the consultation, results entered against them, and a report printed on your letterhead.
Pharmacy Management Software
BuiltA drug catalog with batch and expiry, dispensing tied to the consultation, and the charge on the same invoice as everything else.
Telemedicine Software for Clinics and Hospitals
BuiltBooked like any appointment, checked in under your own fee rules, with the consent and identity check the Telemedicine Practice Guidelines ask for, and a signed prescription in the patient app.
See it running with your own workflows.
Book a walkthrough and we will map your clinic or hospital onto the platform, module by module.