REASON: [Concise description of the presenting issue]
HISTORY: [Comprehensive details of the patient's presenting issue] (Use bullet points and ensure full sentences. Do not omit any details)
(Leave a blank line here for no words to go on)
- Pre-existing conditions: [Detail any pre-existing conditions, if not mentioned write "No known pre-existing conditions"]
- Access to toxins: [List any known access to toxins the patient may have been exposed to/consumed] (If not mentioned write "No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.")
- Current vaccination status: [Describe current vaccination status] (if not mentioned please write "not discussed")
- Current medications: [List current medication, including dosage, frequency and reason for use] (If not mentioned please write "nil mentioned"]
TRIAGE: (Only include what is mentioned)
- HR: [Heart rate in bpm]
- RR: [Respiratory rate in breaths/min]
- Temp: [Temperature in Celsius]
- Mm: [Mucous membrane assessment]
- Crt: [Capillary refill time]
- Mentation: [Choose from either BAR, QAR, Dull, or Obtunded]
- Pain Scale (0-4): [Pain assessment score]
- Hydration status (%): [Clinical assessment of hydration]
- Blood pressure: [Blood pressure in format systolic/diastolic/MAP (if not mentioned please omit from template)]
- Spo2: [pulse oximetry in %] (If not mentioned please omit from template)
EXAMINATION: (For the below examination, each heading must ALWAYS be written, regardless whether it is mentioned in the transcript, contextual note or clinical noted)
Body Condition Score: [Score out of 9 with interpretation if mentioned] (Leave placeholder blank if not mentioned)
Pain Scale (0-4): [Pain assessment score out of 4] (If pain scale has already been mentioned in the history or triage section above, then please leave blank and do not write pain scale.
Cardiovascular: [Findings from cardiac auscultation] (If not mentioned please write "Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous"]
Respiratory: [Findings from thoracic auscultation] (If not mentioned please write "Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge"]
Neurological: [Neurological findings] (If not mentioned please write "Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed"]
Musculoskeletal: [Musculoskeletal findings] (If not mentioned please write "Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed"]
Gastrointestinal:
- Oral: [Describe oral examination findings, including dental score out of 4 if mentioned. (if not mentioned please write "NSF")
- Abdominal: [Abdominal palpation findings] (if not mentioned please write "NSF")
- Rectal: [Rectal examination findings] (if not mentioned please write "not performed")]
Urinary: [Urinary system findings] (if not mentioned please write "NSF"]
Reproductive (incl ext genitalia): [Findings related to reproductive system] (if not mentioned please write "NSF"]
Integumentary system: [Integumentary and ear examination findings] (if not mentioned please write "NSF"]
Lymph Nodes: [Lymph node examination findings] (if not mentioned please write "WNL on palpation")
Eyes: [Ophthalmic examination findings] (if not mentioned please write "NSF"]
PROBLEM LIST:
1. [Primary problem]
2. [Secondary problem]
3. [Additional problem(s)]
DIFFERENTIAL DIAGNOSIS: [List of potential differential diagnoses with brief explanation]
DIAGNOSTICS: [Details of any diagnostics performed] (If none mentioned write "Nil performed")
Baseline Bloods (Only include if mentioned) (Ensure bloods are listed in chronological order)
- PCV: [Packed cell volume result]
- TSP: [Total protein result]
- Serum: [Serum appearance result]
Blood Gas Analysis Results - source: venous (do not include if not mentioned)
- Decreased: [List all Decreased values]
- Increased: [List all Increased values]
-Interpretation: [Interpretation of blood gas analysis]
Bloods were taken for in-house testing:
Full bloods (do not include if not mentioned) (Ensure bloods are listed in chronological order)
- Complete Blood Count
- Please find attached to the patient record.
- Findings: [summarise complete blood count abnormalities]
- Biochemistry
- Please find attached to the patient record.
- [Findings: [Summarise biochemistry abnormalities]
Blood Smear: (do not include if not mentioned)
- Interpretation: [interpretation of blood smear]
Urinalysis in house (do not include if not mentioned)
- Method: [note whether free catch or cystocentesis sample]
- USG: [Urine specific gravity reading]
- Colour: [note colour of urine]
- pH: [note pH of urine]
- Protein: [note whether or not protein present and if trace, small or large amount]
- Blood: [note whether or not blood present and if +, ++, +++]
- Ketones: [note whether positive or negative]
- Glucose: [note whether negative or positive and if positive whether +, ++, +++]
- Wet Prep: [describe wet prep findings if not mentioned write "unremarkable"]
- Dry cytology: [describe cytology findings if not mentioned write "unremarkable"]
AFAST/TFAST: (do not include if not mentioned)
- Peritoneum: [describe free abdominal fluid found] (if not mentioned write "No free fluid was identified in any quadrant")
- Pleural space: [describe location and volume of fluid in pleural cavity] (if not mentioned write "No free fluid was identified in either hemithorax")
- Pericardial space: [note if any pericardial effusion present] (if not mentioned write "No free fluid was identified in the pericardial space")
A blood sample was collected for a coagulation analysis (do not include if not mentioned)
- PT (14-19 sec): [note PT reading]
- APTT (75-105 sec): [note APTT reading]
- Results: [note result as normal or prolonged]
Radiology: (For all radiology examinations that are mentioned, ensure each heading is written, regardless whether it is mentioned in the transcript, contextual note or clinical noted)
Thoracic Views: [Only include this topic if mentioned Thoracic radiographs taken]
- Assessment of extra thoracic structures: [State the key extra thoracic structure findings on imaging] (if not mentioned write "No significant findings")
- Evaluation of the diaphragm: [Diaphragm evaluation on imaging] (if not mentioned write "No significant findings")
- Examination of pleural space: [Describe the pleural space findings on imaging] [If not mentioned write "No evidence of pleural space disease"]
- Analysis of large airways: [Analysis of large airways on imaging] (If not mentioned write "No significant findings"]
- Pulmonary assessment: [Summarise the pulmonary assessment findings on imaging] (If not mentioned write "No significant findings. No evidence of interstitial or alveolar lung pattern")
- Cardiac evaluation: [Summarise the cardiac evaluation on imaging] (if not mentioned write "No significant findings. No evidence of cardiomegaly")
- Oesophageal examination: [Summarise the Oesophageal examination on imaging] (if not mentioned write "Normal location and no evidence of foreign material")
Interpretation: [interpretation of above thoracic view radiology findings] (Always write in full sentences and be detailed)
Abdominal Views: (Only include this topic if mentioned Abdominal radiographs taken)
- Assessment of extra-abdominal structures: [Assessment of extra-abdominal structures on imaging] (If not mentioned write "No significant findings")
- Evaluation of serosal detail: [Evaluation of serosal detail on imaging] (If not mentioned write "Good")
- Liver/spleen examination: [Examination of liver/spleen on imaging] (If not mentioned write "No significant findings. Normal location and appearance.")
- Gastrointestinal tract assessment: [Assessment of Gastrointestinal tract on imaging] (If not mentioned write "No significant findings. No obstructive pattern was noted.")
- Kidney evaluation: [Evaluation of kidney's on imaging] (If not mentioned write "Normal location and shape.")
- Bladder/Prostate examination: [examination of bladder/prostate on imaging] (If not mentioned write "No significant findings")
Interpretation: [interpretation of above abdominal view radiology findings] (Always write in full sentences and be detailed)
Abdominal Ultrasound: (if not mentioned do not include)
- Urogenital Tract: [describe changes to Kidneys, Bladder, Prostate, Uterus on abdominal ultrasound] (If not mentioned write "Bladder had anechoic fluid with no evidence of pathology. The kidneys had a normal location and anatomical structure.")
- Hepato-Biliary System: [describe change to Liver, Gallbladder on abdominal ultrasound] (if not mentioned write "Normal echogenicity and echotexture. No evidence of masses.")
- Gastro-Intestinal Tract: [describe changes to Stomach, Small Intestine, Large Intestine on abdominal ultrasound.] (if not mentioned write "No obstructive pattern noted. A small amount of fluid within the small and large intestine. No masses or abnormalities were noted.")
- Pancreas: [describe any pancreatic changes on abdominal ultrasound] (If not mentioned write "No evidence of pancreatitis.")
- Spleen: [describe any splenic changes on abdominal ultrasound] (If not mentioned write "Normal echogenicity and echotexture. No evidence of masses.")
- Adrenals: [Describe any adrenal changes on ultrasound] (If not mentioned write "Not located.")
- Abdominal Lymph Nodes: [Describe any abdominal lymph node change on ultrasound] (If not mentioned write "No significant findings.")
- Mesentery: [Describe any mesentery changes on ultrasound] (If not mentioned write "No significant findings.")
- Intra-abdominal Fluid: [Describe any intra-abdominal fluid on ultrasound] (If not mentioned write "None located."
ASSESSMENT: [Detailed assessment of patient's condition and plan] (Do not omit any information, write in full sentences and be highly detailed. Clearly summarise events during hospital stay in chronological order)
TREATMENT:
[Details of prescribed treatment/intervention, including medications, dosages, etc] (Be succinct, but do not omit any information)
PLAN:
- [Discharge instructions] (Provide discharge instructions)
- [Recommendations for monitoring and follow-up care] (Provide recommendations for monitoring and follow-up care)
(Never repeat yourself throughout the note. Utilise chronological order when listing blood/diagnostic results. If radiology has occurred, ensure every body system in the above template is written. Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)