Medical WR template

WR Dr , Cons/SpR

Age & sex

Issues
1.
2.
3.

PMH as previous noting

Obs
: NEWS

Investigations
Bloods (date):
VBG (date):
CXR (date):
ECG (date):

On review
DRAFT / PT NOT SEEN YET

O/E
Alert, oriented, answering questions appropriately
Chest ; HS I+II+0
Abdo SNT
Calves SNT
Neuro – grossly intact

R: for full escalation / TEAL in place
E: reg meds as prescribed ± abx
M: no concerns
I: bloods as above
N: E+D ok
D: enoxaparin 40 mg

Plan

Medical clerking proforma

Medical clerking - F1 J Loo
On-call consultant:
Clerking location: ED / MAU

Age & sex
PC:

HPC:

PMH:

Reg meds:

Allergies: NKDA

FHx:

SHx:
Lives at home with
iADL
Smoking - incl weed
Alcohol -
Travel -

O/E:
Alert, oriented, answering questions appropriately
Chest clear, equal air entry bilaterally / crackles / wheeze
HS I+II+0
Abdo SNT, no masses/organomegaly, no guarding
Radial pulses - regular rhythm, good volume
Calves SNT
GCS 15, PEARL 3mm; grossly neurologically intact

Obs: NEWS
Bloods:
VBG:
Micro:
ECG:
CXR:
Other Ix:

Problem list / DDx:

R: for full escalation at present
E: reg meds as prescribed
M: no concerns
I: bloods
N: E+D ok
D: enoxaparin 40 mg

Plan


Cardiovascular smx

Chest pain [see 01.11]
Dyspnoea
Palpitations
Oedema
Calf pain
LOC

Neuro smx

Headache
Changes to vision / motor / sensation
LOC

Respiratory smx

Chest pain
Dyspnoea
Cough (dry/wet)
Sputum
Haemoptysis
Wheeze

Derm / rheum smx

Rash / ulcers
Joint pain
Muscular pain
Fever

GI smx

Abdo pain/distention [see 03.10]
Nausea/vomiting
CIBH – constipation/ loose stools
Blood in vomit / blood in stools
Swallowing issues

General smx

Fever
Weight loss
Night sweats

GU smx

Burning/stinging
Frequency, urgency, nocturia
Oliguria / anuria / polyuria
Polydipsia

Medical discharge

Summary:

Name is a blank-year-old lady who presented to the Emergency Department of Birmingham Heartlands Hospital on DATE with (symptoms). The history and clinical examination were in keeping with xxx. She was admitted for observation and supportive care. [More deets.] As she is now clinically stable, we are discharging her.

Name is a blank-year-old gentleman who presented to the Emergency Department of Birmingham Heartlands Hospital on DATE with (symptoms). The history and clinical examination were in keeping with xxx. He was admitted for observation and supportive care. [More deets.] As he is now clinically stable, we are discharging him.

Disclaimers to add at end of discharge letters

Kindly note that this discharge summary has been prepared based on documentation by my colleagues; this doctor has not been personally involved in the management of this patient.

Kindly note that this discharge summary has been prepared by a colleague; this doctor has not been personally involved in the management of this patient.

Information given to patients:

Please go to your nearest A&E should you become unwell after your discharge (e.g. if you experience uncontrollable pain, if you develop a high fever, etc).

Information given to GP:

Dear colleague, kindly note the recent admission of this patient.