Documenting a cardiology round

aurii drafts the progress note, the GP and referrer letters and the discharge summary from one spoken review.

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Spoken at the bedside

Day two after an NSTEMI, on a synthetic patient.

Spoken at the bedside Ambient capture

"Day two after the NSTEMI. No chest pain overnight, obs stable, nothing on telemetry, and the GTN infusion came off overnight."

"Trop has peaked and is trending down, and this morning's ECG shows the anterolateral changes resolving, nothing new. Continue dual antiplatelet and the high-intensity statin, echo before the angiography decision."

"JVP's not up, chest is clear, trace of peripheral oedema, so she's euvolaemic. Start the ACE inhibitor low, and recheck renal function and potassium in forty-eight hours before we up-titrate."

"Her AF is rate controlled. Keep up-titrating the beta-blocker as tolerated, and anticoagulation continues per the admission plan."

"Echo today please, and repeat renal function and electrolytes in forty-eight hours."

"Refer her to cardiac rehab, and a letter to the referring GP on discharge with the reconciled medication list."

Progress note Post-NSTEMI review, day 2 · Demo patient · 68 · Bed 9

Ready to sign

Overnight

No recurrence of chest pain. Haemodynamically stable, no arrhythmia on telemetry. GTN infusion weaned overnight and ceased.

Problem 1 · NSTEMI

Troponin peaked and now trending down. ECG this morning shows resolving anterolateral changes, no new deviation. Continue dual antiplatelet and high-intensity statin. Awaiting inpatient echo before the angiography decision.

Problem 2 · Heart failure, mild

JVP not elevated, chest clear, trace peripheral oedema. Euvolaemic on examination. ACE inhibitor started at a low dose. Recheck renal function and potassium in 48 hours before up-titration.

Problem 3 · Rate and rhythm

Background atrial fibrillation, rate controlled. Beta-blocker up-titrated as tolerated. Anticoagulation continued per admission plan.

Plan

Echo today
Renal function and electrolytes in 48 hours
Cardiac rehabilitation referral
Referrer letter to the referring GP on discharge with the reconciled medication list

Synthetic demo patient.

GP letterDrafted Discharge summaryQueued Billing3 items

Documents from one ward review

Draft The progress noteEach problem on its own: the infarct, rate and rhythm, fluid status, renal function.

Draft The lettersTo the referring GP: the event, the investigations, the medication changes and what to monitor. To the original referrer: the diagnosis, the results, and whether cardiology keeps reviewing or hands care back.

Draft The discharge summaryDiagnosis, the in-hospital course, the reconciled medication list, the cardiac rehabilitation referral and the follow-up plan.

Billing items are captured at the bedside against the episode, for your practice to claim. Billing.

Cardiology note templates

Your letterhead and section order, set once, on every draft. The template set.

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