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Primary Care Physician
15-20 minutes

Toxicology Report

The s10.ai Toxicology Note template is expertly crafted for General Practitioners to efficiently document cases of suspected or confirmed drug overdose. This comprehensive template encompasses sections for presenting complaints, risk assessment, clinical features, and management plans, ensuring thorough documentation of the patient's condition and treatment strategy. It is particularly advantageous for recording critical details such as drug ingestion time, dosage, and decontamination measures. Additionally, the template supports the inclusion of pertinent medical history, current medications, and social factors influencing the patient's health. This structured approach enhances the delivery of effective care and facilitates planning for further investigations or referrals, motivating clinicians to adopt and implement this essential tool in their practice.

2,714 uses
4.4/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

s10.ai Toxicology Assessment Review
Age and Sex [Mention the patient’s age and sex] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PRESENTING COMPLAINT:
[Details of the reason for visit, current issues including relevant signs and symptoms, as well as associated signs and symptoms]
RISK ASSESSMENT
Time of ingestion: [Mention patient’s drug time of ingestion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Drug and dose: [Mention patient’s overdosed drug name or names, formulation and dose] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Decontamination: [Mention if the patient has received activated charcoal or has had vomiting since the overdose] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History:
[Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
Medications:
[Current medications and dosages]
Allergies:
[Any known allergies, particularly to medications]
Substances:
[Alcohol consumption habits (if applicable)]
[Any illicit drug use (if applicable)]
[Current or past smoking history (if applicable)]
Social history:
[Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Current or previous occupation (if applicable)]
CLINICAL FEATURES
[Mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[General state of health and any notable findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
WORLD backwards:
[Physical examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Mention if the patient has been able to mobilise] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Mention if the patient has been able to pass urine] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Observations
[Vital signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Investigations
[Investigations with results] (you must only include completed investigations, and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under CLINICAL FEATURES; instead, all planned or ordered investigations must be included under PLAN.)
MANAGEMENT
Supportive cares
[Mention if the patient has received any treatment including sedation, intravenous fluids, antidote or other specific treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
IMPRESSION
[Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
PLAN
[Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(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.)
Sample Clinical Note

Example of completed documentation using this template

Clinical Toxicology Unit Review
Age and Sex: 32-year-old female
PRESENTING COMPLAINT:
The patient arrived with confusion and drowsiness after a medication overdose. She reported experiencing nausea and abdominal discomfort.
RISK ASSESSMENT
Time of ingestion: Approximately 3 hours before arrival
Drug and dose: Paracetamol, 20 tablets of 500mg each
Decontamination: The patient has vomited twice since the overdose
History:
The patient has a history of depression and anxiety, for which she is on medication. No significant surgical history. No previous overdoses.
Medications:
Sertraline 50mg daily
Allergies:
No known drug allergies
Substances:
Occasional alcohol consumption, no illicit drug use, non-smoker
Social history:
The patient is a teacher and lives alone. She has been experiencing increased stress at work.
CLINICAL FEATURES
Mental state examination: The patient is drowsy but responsive to verbal stimuli. Oriented to person but not to time or place.
General state of health: Appears pale and lethargic
WORLD backwards: Unable to perform
Physical examination: Mild epigastric tenderness, no guarding or rebound tenderness
Mobilisation: The patient has not mobilised since the overdose
Urination: The patient has not passed urine since the overdose
Observations
Vital signs: BP 110/70 mmHg, HR 90 bpm, RR 18/min, Temp 36.8°C, SpO2 98% on room air
Investigations
Serum paracetamol level: 150 mg/L
MANAGEMENT
Supportive cares: The patient received intravenous fluids and N-acetylcysteine as an antidote
IMPRESSION
Likely diagnosis: Paracetamol overdose
Differential diagnosis: None
PLAN
Investigations planned: Repeat serum paracetamol level in 4 hours
Treatment planned: Continue N-acetylcysteine infusion
Relevant other actions: Referral to psychiatric services for further assessment and counselling
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Clinical Toxicology Unit Review template is an essential tool for healthcare professionals managing cases of drug overdose and poisoning. This comprehensive template facilitates a detailed assessment of the patient's presenting complaint, risk factors, and clinical features, ensuring a thorough evaluation of the patient's condition. It includes sections for documenting the time of ingestion, specific drugs and dosages involved, and any decontamination measures taken, such as activated charcoal administration. The template also covers the patient's medical history, current medications, allergies, and social history, providing a holistic view of the patient's background. Clinicians can record vital signs, mental state examinations, and physical findings, aiding in accurate diagnosis and management. The management section allows for the documentation of supportive care measures and planned investigations, ensuring a structured approach to treatment. By adopting this template, clinicians can enhance their documentation efficiency, improve patient care outcomes, and streamline communication within the healthcare team. Explore the Clinical Toxicology Unit Review template to optimize your clinical workflow and ensure comprehensive patient assessments.
Frequently Asked Questions

Common questions about this template and its usage

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