Progress Documentation - [Hospital Unit] (example is 3 west, 3 south, 4 north etc. including bed and room if mentioned)
ID:
- [Patient age], [Patient gender]
- [Level of Care] (always include between A, B, C, D and write as "Level of Care" then the letter and between brackets discussed if not included then Write in bracket "assumed A but to be discussed")
Reason for admission:
- [Reason for admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Medical History:
- [Past medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies
- [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Today:
- [Current symptoms and complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
OE:
- [Vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Physical examination findings] (if I say insert hospital exam write
" Good General State, no distress, no work for breathing
Heart: normal S1, normal S2 with no murmurs
No LL Edema
Lungs: Normal Vesicular breathing, No crackles, No wheezing
Abdomen: Soft, no tenderness, no Rigidity, no Rebound, negative Mcburney sign")
Investigations:
Labs:
- [Laboratory results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise write "no new labs")
Imaging:
- [Imaging results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, write "no new imaging")
- [Other diagnostic tests] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Treatment Plan:
[1. Issue, problem, or request 1 (issue, request or condition name only)]
- [Impression, likely diagnosis for Issue 1 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Differential diagnosis for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Investigations planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Treatment planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Relevant referrals for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
[2. Issue, problem, or request 2 (issue, request or condition name only)]
- [Impression, likely diagnosis for Issue 2 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Differential diagnosis for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Investigations planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Treatment planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Relevant referrals for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
[3. Issue, problem, or request 3, 4, 5 etc. (issue, request or condition name only)]
- [Impression, likely diagnosis for Issue 3, 4, 5 etc. (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Differential diagnosis for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Investigations planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Treatment planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Relevant referrals for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Current treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Medications administered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Interventions performed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[4. Discharge Planning & Other:] (always include giving it the next number after all medical issues listed above)
- [Expected date of discharge] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank, include it as the before last issue/problem include it as before last issue/problem give it the next number in issues)
- [Prophylactic anti-coagulation] : (Has to be included in note, can insert from hospital medication above if heparin, fragmin, lovenox, eliquis/apixaban or other anticoagulation)
- [Foley cathéter:] (Has to be included in note either yes or no and highlight if not mentioned in transcript)
- [GFR/Kidney function: ] (use GFR or creatinine mention in the labs section)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)