Template

Update Template

Medical ST4 Miller Clerking

Presenting Complaint:
[The reason for the patient attending, the presenting complaint, aiming for 1 to 3 words and up to one sentence only. For example: haematemesis, melaena]

History of Presenting Complaint:
[In note format, include key symptoms or events related to the patient's presenting complaint  using short sentences. Do not include the patient's name. Also include relevant information from any relatives and any other professionals]

Past Medical History:
[A bulleted list of the medical problems the patient has had in the past, if diabetes is mentioned, include the latest HbA1c (if mentioned). If asthma or COPD is mentioned, include any lung function studies (if mentioned)]

Medication History:
[A list of the patient's current medications e.g. Atorvastatin 20mg PO ON]

Allergic History:
[If mentioned, include any allergies here]

Social History:
[Include here information about the wider social situation of the patient. Who they live with, if they have a package of care, how they move around and if they drink alcohol or smoke cigarettes, if mentioned]

On Examination:
[Any relevant examination findings mentioned]

Investigations:
[A list of investigations mentioned, if you have already included these in the past medical history field, do not repeat them here]

Impression:
[The impression, the diagnosis or diagnoses]

Plan:
[A numbeed list of actions, the plan for the patient's admission, include an empty box ("[_]") after each item])]