EMR & SOAP notes
Structured electronic medical records with autosave, coded terminology and ambient AI scribe.
Overview
A modern EMR designed for clinicians, not coders. SOAP, BIRP and DAP templates, vitals graphs, growth charts, problem list, allergies and full visit history in a single fast workspace that loads in under a second on any device.
Why it matters
Most EMRs were designed for billing, not for the consult room. Clinicians end up typing after-hours just to close charts. Onzira flips this — the AI scribe drafts the note while you talk, templates handle 80% of the structure, and autosave means you never lose a keystroke.
Capabilities
Every capability is included in the box — no add-ons, no surprise upgrades.
- SOAP / BIRP / DAP templates per specialty
- ICD-10/11, SNOMED CT, LOINC and CPT coding
- Voice dictation and ambient AI scribe
- Drug interaction and allergy warnings inline
- Vitals graphs, growth charts and BMI tracking
- Problem list, allergies, family and social history
- Consent capture with digital signatures
- Offline autosave with conflict resolution
How teams use it
A typical day-in-the-life workflow our customers run on this module.
- Patient is queued from reception; chart opens with full history
- Vitals flow in from the nurse's tablet
- Ambient scribe records the consult and drafts SOAP
- Doctor reviews, adds plan, signs and locks the note
- Rx, lab orders and follow-up appointment generated in one click
Integrations
Connect with the tools your clinic already uses.
- Lab analysers (LIS / HL7 v2)
- PACS / DICOM viewers
- ABDM / ABHA national health stack
- FHIR R4 endpoints
- Pharmacy POS
Security & compliance
Enterprise-grade controls on by default.
- Field-level access controls
- Immutable per-field audit log
- Consent and disclosure tracking
Outcomes
What customers typically see within the first 90 days.
- Notes completed during the visit, not after hours
- Zero data loss with offline autosave
- Coding-ready charts for insurance and audits
- Doctor admin time down 60%