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Update Template
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] 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)] Diagnosis: [The diagnosis mentioned in the dictation or transcription. If not mentioned, insert your diagnosis based upon the information provided] I had the pleasure of meeting [patient name] in Same Day Emergency Care today. [A letter to the GP documenting the clinical consultation. Include the patient's symptoms, pertinent past medical history, examination findings and pertinent investigation results (if mentioned)] Investigations: [A list of investigations and their results] Plan: [A numbered list consisting of the plan following the patient's attendance.]
Update Template