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I would add plea for letters to contain explicit commentary on exactly what the patient who has been given a grave diagnosis during admission has been told , and of course for this info' to reach GP quickly! So would proper structure and content of electronic patient records help in improving the discharge process? This could allow for certain data to be automatically populated in discharge letter and make it easier for the doctor to select the rest of the information that would need to go in.

The electronic version could be sent directly to GP, patient, and other carers who would need the information. Could there be an agreement to these common standards, would the technology ever allow you to do this easily, quickly, and safely beating the paper version? I received a brief discharge letter about a routine hernia operation.

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He was discharged home it said. I eventually met the patient 6 weeks later and he looked awful, He told me that he never had the operation as he had a cardiac arrest in the anaesthetic room and was sent to cardiac ICU! I never received anything about that bit. The lack of useful data in discharge summaries can be frustrating. Also why is a BP never mentioned? American discharge summaries are a bit ott but they do give a good picture of the patients actual treatment and state of health on discharge.

Site Search User. Home Connecting doctors The Secret Doctor The rambling, the random and the raw - the art of the discharge letter. Connecting doctors. Share Subscribe by email More Cancel. In my experience, there are essentially three approaches to writing one.

She lived happily ever after, as far as we know. Read more experiences at the Secret Doctor blog and follow on Twitter What are your top tips for the perfect discharge letter? Join the discussion. When it comes to discharge letters, no letters require more work than those for COTE patients. I wish I knew. Diagnosis es Recommendations for GP to consider then anything you like! Consultant discharge letter: This lady was admitted to my ward.

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The patient describes an eight-month history of anxiety symptoms, which began two months after a car accident. Lecturer's comment 1: Central problem.

USMLE STEP 2 CS Practice Timer - Patient encounter plus Patient note

She experiences apprehensiveness when out of her home, inability to cope with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially. Lecturer's comment 2: Common psychiatric symptoms. More recently she has had trouble concentrating on her work. Lecturer's comment 3: Effect on work. Five days ago she was taken to her local GP after experiencing a typical attack in the supermarket. Lecturer's comment 4: This is the precipitant.

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She has become housebound since, ruminating that "I'm terrified of suffering a heart attack and dying suddenly like my mother". She has begun drinking up to a bottle of wine a day Lecturer's comment 5: Impact of illness on work, social relations, and self-care. Lecturer's comment 6: The history is documented from the patient's perspective. The facts recorded must be based on the patient's description. Where appropriate, incorporate the patient's own words into the report. You may choose to commence this section of the report with a summary of the key issues that you will address, as in the example shown.

The central problem is identified promptly in the first sentence, and relevant key symptoms are outlined immediately in the second sentence. This is important information in an objective diagnostic work-up. Information on the impact of illness is placed next, helping to contextualise the patient's experience of the central problem and related symptoms. This information will contribute toward a more sophisticated diagnosis that accommodates the patient's experience and response to illness.

Note that in the example all symptoms whether present or not relevant to a diagnosis of anxiety and the differential diagnosis have not been included. This is OK for an introduction but not for the history of presenting complaint. Many psychiatric illnesses are recurrent or have an acute-on-chronic course, so that the link between the present illness and past psychiatric history may be strong.

This is the rational for describing the past psychiatric history immediately after the present illness. Bloch and Singh By including this sort of information, you will build a picture of the pattern of illness chronicity, severity, coping strategies, crisis triggers, etc. Lucy has a 4-week history of severe headache. Initially, Lucy reported a disturbance in her vision, saying that she saw "purplish-black colour spots" in her vision.

This was followed by the onset of a severe headache located at the right frontal and temporal regions, radiating to the right occipital area.

Assessment of junior doctors’ admission notes: do they follow what they learn?

The headache commenced as mild and dull pain then became severe and throbbing in nature. It was worsened by straining and coughing. Lucy likened the pain to "being stabbed and squeezed by someone continuously" and described the headache as the most horrible she had ever had. Lucy's GP prescribed her Panadol. The medication did not help and Lucy started to experience nausea, vomiting, and mild photophobia. She also experienced pain at the nape of her neck. An angiogram showed signs of venous blockage in the retinal veins.

The headache persisted, and 3 weeks after it commenced, Lucy was becoming more worried about it. She was experiencing 4 sleep disturbance, poor appetite and weight loss she reports losing 5kg over three weeks. At the time, Lucy resigned from work, thinking that her symptoms were stress-related and she probably needed a break. Lucy also sought a second opinion from another GP. A CT scan revealed a tumour in the right frontal lobe, which was causing oedema and a mid-line shift. Lucy was immediately admitted to MMC for biopsy of the tumour. Lecturer's comment 1: The report commences with an account of events in the past.

In the first two paragraphs, events and experiences are predominantly expressed in the past tense. The past tense is used to refer to events in the patient's history that occurred prior to the interview and are squarely placed in the past.

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Although related to the Presenting Complaint, the assumption of relevance to the current presentation is no longer immediate. Compare with the use of the present perfect tense, below: "Initially, Lucy reported a disturbance in her vision Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health.

Lucy has experienced two nights of restless sleep. She has lost enthusiasm for her usual activities, such as going shopping and taking care of her son. She reports having no energy for maintaining her work or social life. She has also become more irritable and aggressive, which is putting additional pressure on her family. She admits to being preoccupied with thinking about her illness and is having trouble concentrating on daily activities.

She reports feeling tired but too scared to sleep for fear that she will not wake in the morning. Lecturer's comment 2: The report moves closer to present time. In the third paragraph, the present perfect tense predominates. The present perfect tense is used to refer to events in the patient's history that occurred prior to the interview but still bear current relevance. In the history, you may describe signs and symptoms that began in the past and are still continuing: "Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health.

Can they come to the correct conclusions? If not, re-calibrate. It's O. In general, try to give your presentations on a particular service using the same order and style for each patient, every day. There are a number of common presentation-types, each with its own goals and formats. These include: Daily presentations during work rounds for patients known to a service. Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics. Purpose: Organize the presenter forces you to think things through Inform the listener s of 24 hour events and plan moving forward Promote focused discussion amongst your listeners and supervisors Opportunity to reassess plan, adjust as indicated Demonstrate your knowledge and engagement in the care of the patient Duration: Rapid 5 min presentation of the key facts Key features of presentation: Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue s.

Example of a daily presentation for a patient known to a team: Opening one liner: This is Mr. Labs and imaging remarkable for: Creatinine. Issues are as follows: Cellulitis complicated by abscess , which has now been adequately drained. Exam improved and feels better. Now BP is climbing back to hypertensive range. On admission AKI due to sepsis. All improved as expected with control of infection. Wound care teaching with RNs today — wife capable and willing to assist. Set up follow-up with PMD to reassess wound and cellulitis within 1 week. Purpose Organize the presenter forces you to think things through Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis. It often includes a limited listing of their other medical conditions e. History of present illness HPI : The history is presented highlighting the relevant events in chronological order.

Events are best presented as temporally oriented bullets from the starting point of the illness to the present moment , making it easy to follow the sequence in which things progressed. These events are often described based on how many days ago they occurred. For example: 7 days ago, the patient began to notice vague shortness of breath. Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.

Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem s. It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. Review of Systems ROS : Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI.

The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. That said, selective redundancy i. If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation. Family History: Emphasis is placed on the identification of illnesses within the family particularly among first degree relatives that are known to be genetically based and therefore potentially heritable by the patient.

This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. Sexual history if it relates to the active problems. Physical Exam Vital signs and relevant findings or their absence are provided. Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline. The assessment and plan typically concludes by mentioning appropriate prophylactic considerations e. DVT prevention , code status and disposition. HPI: Mr. Approximately 1 week ago, he began to feel dyspneic with moderate activity. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine.

Receives care thru Dr. Smiley at the University HIV clinic. CD4 count 3 months ago was and viral load was undetectable. He is homosexual though he is currently not sexually active. He has never used intravenous drugs. He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease.

Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP. Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints. He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer. Social history, habits Patient works as an accountant for a large firm in San Diego.

He lives alone in an apartment in the city. Smokes 1 pack of cigarettes per day and has done so for 20 years. No current alcohol use. Denies any drug use. Sexual History as noted above; has sex exclusively with men, last partner 6 months ago. Physical Exam notable for: Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system.

Breathing was labored and accessory muscles were in use. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base. Cardiac: JVP less than 5 cm; Rhythm was regular.