Documenting an ENT day list

aurii drafts the procedure note, the letter to the GP and the discharge summary from one spoken review.

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Spoken in recovery

A day-case tonsillectomy reviewed before discharge, on a synthetic patient.

Spoken in recovery Ambient capture

"Adult tonsillectomy this morning. She is awake, comfortable and drinking."

"Throat pain is settled on regular paracetamol and an anti-inflammatory, and she is swallowing without difficulty."

"The fossae are clean, no bleeding, no clot, and the uvula is not swollen."

"Observations are stable and she has taken two hundred millilitres in recovery without vomiting."

"Home this afternoon on regular analgesia, with instructions to come straight back for any bleeding."

"Letter to her GP with the analgesia plan and the bleeding advice."

Progress note Post-tonsillectomy, day case · Demo patient · 27 · Bay 3

Ready to sign

Procedure and progress

Adult tonsillectomy performed this morning. Awake, comfortable and tolerating oral fluids. Pain controlled on regular paracetamol and an anti-inflammatory. No dysphagia.

Examination

Tonsillar fossae clean, no active bleeding and no clot. Uvula not oedematous. Observations stable. 200 mL oral intake in recovery without vomiting.

Plan

Discharge this afternoon
Regular analgesia for ten days
Return immediately for any bleeding
GP letter with the analgesia plan and the bleeding advice

Synthetic demo patient.

GP letterDrafted Discharge summaryQueued Billing3 items

Illustration of the drafting view.

The advice, written once

aurii drafts the operative note, the discharge summary and the GP letter from one spoken review, so the analgesia, the bleeding advice and the return criteria the patient heard are the words the GP reads. The surgeon signs each.

Documents from one day-case review

Draft The progress noteThe procedure performed, pain control and oral intake, examination of the operative site, and the plan for discharge.

Draft The procedure noteIndication, the procedure performed, the findings, how haemostasis was achieved and what the patient is discharged on.

Draft The lettersTo the referring GP: the operation, the analgesia plan, the bleeding advice given and when the patient is reviewed. To the referring specialist: what was found and whether a further procedure is planned.

Draft The discharge summaryThe operation, the recovery, the medication supplied, the warning signs the patient was told to act on and the follow-up appointment.

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

Starter templates an ENT list draws on

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

The advice the patient leaves with

The GP letter drafts from the same review as the note: the operation, the analgesia plan, the bleeding advice and the review date. The surgeon signs it before it goes.

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