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The prescriptions module enables physicians to create comprehensive medical prescriptions that include ICD-10 diagnosis codes, multiple medications with detailed dosing instructions, and general patient guidance. Each prescription is automatically numbered and timestamped for record-keeping.

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Overview

The prescription system provides:

ICD-10 diagnosis

Search and select diagnoses from the official CIE-10 catalog

Medication search

Autocomplete medication database with commercial names and concentrations

Detailed dosing

Specify dose, frequency, duration, route, and special instructions

Prescription history

View all past prescriptions in collapsible timeline format

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Key features

The diagnosis search component allows you to:
  • Search the official CIE-10 (ICD-10) catalog by code or name
  • View catalog key and full description
  • Select primary diagnosis (required)
  • See selected diagnosis with its complete code (e.g., “A09 - Diarrea y gastroenteritis de presunto origen infeccioso”)

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Medication autocomplete

As you type medication names, the system:
  • Searches the medication database for matching commercial names
  • Displays suggestions with concentration and presentation
  • Auto-fills medication details when you select a suggestion
  • Allows manual entry if medication not found in database

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Prescription form fields

Prescription header:
  • Prescription number (auto-generated, format: RX-XXXXXXXX)
  • Primary diagnosis (CIE-10, required)
  • General instructions (optional)
Each medication:
  • Commercial name (required, with autocomplete)
  • Concentration (e.g., “500mg”, “250mg/5ml”)
  • Presentation (Tableta, Cápsula, Jarabe, Suspensión, Inyectable, Crema, Pomada, Gotas)
  • Dose (required, e.g., “1 tableta”, “5ml”)
  • Frequency (e.g., “Cada 8 horas”, “Dos veces al día”)
  • Duration (e.g., “7 días”, “2 semanas”)
  • Total quantity (e.g., “30 tabletas”, “120ml”)
  • Route of administration (Oral, Intravenosa, Intramuscular, Subcutánea, Tópica, Oftálmica, Ótica, Nasal)
  • Additional instructions (optional, medication-specific notes)

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Prescription history

Past prescriptions are displayed with:
  • Date and time of creation
  • Prescription number
  • Primary diagnosis
  • Complete medication list with all details
  • General instructions
  • Collapsible/expandable view for easy browsing

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How to use

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Creating a new prescription

1

Select a patient

Navigate to “Pacientes” and select the patient for whom you’re prescribing. You must have an active patient selected.
2

Access prescriptions

Click on “Recetas Médicas” in the main menu
3

Enter primary diagnosis

In the “Diagnóstico Principal (CIE-10)” field:
  • Type to search the CIE-10 catalog
  • Select the appropriate diagnosis from the dropdown
  • The full code and description will be displayed
4

Add general instructions (optional)

Use the “Instrucciones Generales” text area for prescription-wide guidance, such as:
  • “Tomar con alimentos”
  • “Evitar alcohol durante el tratamiento”
  • “Tomar mucha agua”
5

Add medications

For each medication:
  1. Type the medication name - The autocomplete will show matching medications
  2. Select from suggestions (or continue typing to enter manually)
  3. Verify/edit concentration - Auto-filled if selected from database
  4. Select presentation - Choose from dropdown
  5. Enter dose - Required (e.g., “1 tableta”, “10ml”)
  6. Enter frequency - How often to take (e.g., “Cada 12 horas”)
  7. Enter duration - How long to take it (e.g., “10 días”)
  8. Enter total quantity - Total amount to dispense (e.g., “20 tabletas”)
  9. Select route - Choose from dropdown (defaults to Oral)
  10. Add special instructions - Optional medication-specific notes
Click “Agregar Medicamento” to add the medication to the prescription
6

Review medications

Review the list of added medications. You can remove any by clicking the X button next to it.
7

Save prescription

Click “Guardar Receta” to save. The prescription will be added to the patient’s history.
Required fields are marked with an asterisk (*). You must enter at least one medication with a name and dose, plus a primary CIE-10 diagnosis.

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Viewing prescription history

1

Select the patient

Ensure the correct patient is selected
2

Access prescriptions

Navigate to “Recetas Médicas”
3

Browse history

Scroll to the “Historial de Recetas” section to see all past prescriptions
4

Expand prescription

Click on any prescription to expand and view:
  • Full diagnosis
  • All medications with complete details
  • General instructions
The prescription history shows the total number of prescriptions for the patient in a badge (e.g., “15” prescriptions).

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Medication search best practices

Using the medication autocomplete:
  1. Type at least 3 characters to trigger suggestions
  2. Look for the medication by commercial name (e.g., “Amoxicilina”, “Paracetamol”)
  3. When you see your medication in the list, click to select it
  4. The system will auto-fill concentration and presentation
  5. Verify the auto-filled values are correct for your intended prescription
If medication not found:
  1. Continue typing the full name
  2. Manually enter concentration and select presentation
  3. The prescription will still be valid - you’re not limited to the database

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Prescription presentation types

DoctorSoft+ supports these medication presentations:
Solid oral dosage form. Common for antibiotics, pain relievers, and chronic medications.
Gelatin shell containing medication. Often used for powders or liquid medications.
Liquid medication with sweet taste. Common for pediatric medications and cough suppressants.
Liquid with medication particles suspended. Must be shaken before use.
Sterile solution for injection. Specify route (IV, IM, SC) in administration route.
Topical semi-solid emulsion. Used for skin conditions.
Greasy topical preparation. Provides occlusive effect for skin.
Liquid for drop-wise administration. Specify route (ophthalmic, otic, oral).

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Routes of administration

Select the appropriate route for each medication:
  • Oral: By mouth (tablets, capsules, syrups)
  • Intravenosa: Intravenous injection
  • Intramuscular: Intramuscular injection
  • Subcutánea: Subcutaneous injection
  • Tópica: Applied to skin (creams, ointments)
  • Oftálmica: Eye drops or ointments
  • Ótica: Ear drops
  • Nasal: Nasal spray or drops

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Dosing instruction examples

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Example 1: Antibiotic for infection

Nombre Comercial: Amoxicilina
Concentración: 500mg
Presentación: Cápsula
Dosis: 1 cápsula
Frecuencia: Cada 8 horas
Duración: 7 días
Cantidad Total: 21 cápsulas
Vía: Oral
Instrucciones: Tomar con alimentos para reducir molestias estomacales

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Example 2: Pain management

Nombre Comercial: Paracetamol
Concentración: 500mg
Presentación: Tableta
Dosis: 1-2 tabletas
Frecuencia: Cada 6 horas según necesidad
Duración: 5 días
Cantidad Total: 20 tabletas
Vía: Oral
Instrucciones: No exceder 4 gramos (8 tabletas) en 24 horas

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Example 3: Pediatric syrup

Nombre Comercial: Ambroxol
Concentración: 15mg/5ml
Presentación: Jarabe
Dosis: 5ml
Frecuencia: Cada 12 horas
Duración: 5 días
Cantidad Total: 120ml
Vía: Oral
Instrucciones: Administrar después de las comidas. Agitar antes de usar.

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Example 4: Topical application

Nombre Comercial: Betametasona
Concentración: 0.1%
Presentación: Crema
Dosis: Aplicar capa fina
Frecuencia: Dos veces al día
Duración: 7 días
Cantidad Total: 30g
Vía: Tópica
Instrucciones: Aplicar solo en áreas afectadas. No cubrir con vendaje oclusivo.

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Best practices

The primary diagnosis is required for insurance claims and medical-legal documentation. Take time to find the most accurate ICD-10 code.
Include exact amounts (“1 tableta”, not “una”) and clear frequencies (“Cada 8 horas” instead of “3 veces al día”) to avoid confusion.
Verify the total quantity matches the dose × frequency × duration. For example: 1 tablet every 8 hours for 7 days = 21 tablets.
Include important information like:
  • Timing relative to meals
  • What to do if a dose is missed
  • Storage requirements
  • Warning signs to watch for
Always check the patient’s allergy list (in their patient record) before creating a prescription.
Use the general instructions field for prescription-wide guidance that applies to all medications or the treatment plan as a whole.

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Prescription numbering

Each prescription receives a unique number in the format RX-XXXXXXXX, where:
  • RX- is the prefix indicating a prescription
  • 8 digits based on timestamp for uniqueness
This number:
  • Is auto-generated when you open a new prescription form
  • Can be manually edited if needed (e.g., to match paper prescription books)
  • Appears in the prescription history for easy reference
  • Can be used to track prescriptions across the practice
If you navigate away from the prescription form without saving, you’ll need to manually update the prescription number when you return, or let the system generate a new one.

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Integration with patient records

Prescriptions are:
  • Patient-specific: Tied to the selected patient
  • Chronologically ordered: Newest prescriptions appear first in history
  • Permanently stored: Cannot be edited or deleted after creation
  • Fully detailed: Every field is stored and displayed in history
This creates a complete medication history for each patient, supporting:
  • Treatment continuity
  • Medication reconciliation
  • Insurance claims
  • Medical-legal documentation
  • Patient education (“Here’s what I prescribed last time…”)

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