My clinical documentation template

My clinical documentation template
Matt Green @MLG1611, September 2017

[Consider your name, role and time/date; especially if adding to someone else’s paperwork]. This format assumes lots of data has been captured elsewhere on the patient report form.

On arrival: ABC [tick is present, cross if absent]/where the patient is/other important people on scene/any ongoing treatment.

Presenting complaint: 1-2 words and duration

History of presenting complaint: 1-3 short sentences, culminating in trigger for ambulance call/dispatch

On examination:

Central nervous system [As appropriate GCS, capacity assessment, FAST, seizure details, head injury, loss of consciousness, nausea/vomiting etc]

                Respiratory system [Auscultation, cough, sputum, smoking history, pleuritic pain etc]

Cardiovascular system [Central and peripheral perfusion, comments on heart rate/blood pressure, ECG analysis, description of pain and other relevant symptoms, total external blood loss]

Gastrointestinal system [Inspection, auscultation, palpation, percussion, last vomiting, bowels last opened]

                Genitourinary system [Normal/abnormal with description, urine analysis]

                Musculoskeletal system [Injuries, trauma, mobility, spinal assessment]

                Skin [Wounds, pallor/flushed, poor turgor]

                [Optional] Mental health/obstetrics and gynaecology/ear nose and throat/nutrition

[Comment on known important baseline issues as appropriate]

Impression: Working diagnosis [may be very specific or more general where aspects are not yet fully explained]

Plan: History, observations, assessment, treatment given, referrals made

Advice [if discharged]: To keep safe, to rest, to eat and drink well, to see GP for review, to use medications as per label, to call 111 for medical help as required, to call 999 if very concerned or unwell. Left alone/in care of X

Past medical history

Medications

Allergies [name as suggested by patient, and how the allergy presents]

Immunisations [where appropriate]

Social history

[Line and initials to prevent further entries]

For example:

M. Green, Clinical Supervisor, 0845 10/9/17. OA: ABC. Sat on sofa. CFR and family OS. PC: SOB 6/24. HPC: MI 6/52 ago. Recent SOBOE; now SOB at rest today. Family visited; concerned. 999->Amb. sent. OE: CNS: GCS=15/15. Capacity. Nil pain. Pupils=5mm BL. Nausea. RS: RR24. SOB/SOBOE++. Productive cough with frothy sputum. Ex-smoker; 40 pk years. SP02=93%OA. Auscultation: BL coarse crepitations in mid and lower lobes; little change with cough. CV: Warm peripheries. Nil chest pain. HR/BP as recorded. Nil sweating. 12-lead ECG; LBBB; known in patient. BL ankles; new pitting oedema. GIT: Nil vomiting. SNT. Normal bowel sounds. BLO this am. Normal food intake. GUS: Denies complaint. MSS: Mobile, nil reported trauma. Ongoing lower back pain with nil acute change. Skin: Apyrexic. Nil acute change. IMP: Acute heart failure after recent MI. Plan: Hx, obs, assess, oxygen to 94-98% SP02, nebulise 5mg SLB, GTN, IV access, consider furosemide depending on response to other Tx. To ED. R/V on route. PMH: MI 6/52 (2xstent), angina, hypertension, high cholesterol, NIDDM. Medication: Aspirin, clopidogrel, metformin, simvastatin, bisoprolol
Allergies: Penicillin (rash on arms). SH: Lives with partner. Mobile, self caring. Part time work as bookkeeper.----MG