Documenting a general medicine admission
Admission notes, daily progress notes by problem, discharge summaries and letters to the GP.
A multi-problem ward round
Day three of an admission with pneumonia, heart failure and type 2 diabetes.
Day three of the right lower lobe pneumonia. Afebrile overnight, sats 95% on one litre nasal prongs.
Reduced air entry right base, no new creps. JVP not up, ankle oedema improving.
CRP 64 from 212. Stop the IV benpen and doxy, oral amoxicillin 1 g TDS to finish seven days in total. Keep the chest physio going.
Heart failure, down 1.2 kilos on frusemide 40 BD. Same dose, daily weights, fluid restrict to 1.5 litres.
She's eating again, so restart metformin 500 BD, her eGFR is 45. Empagliflozin stays held until she's eating and drinking normally. BSLs 9 to 12.
Cr 104, K 4.1, repeat EUC tomorrow. Start the discharge summary and the GP letter.
1. CAP, right lower lobe, day 3
Afebrile overnight. SpO2 95% on 1 L NP. Reduced AE R base, no new creps. CRP 64 (212 on admission). IV benzylpenicillin and doxycycline ceased; amoxicillin 1 g PO TDS to complete 7 days total. Chest physio to continue.
2. Heart failure
JVP not elevated, ankle oedema improving. Weight down 1.2 kg. Continue furosemide 40 mg BD. Daily weights, fluid restriction 1.5 L.
3. Type 2 diabetes
Eating. BSL 9 to 12. Recommence metformin 500 mg BD (eGFR 45). Empagliflozin withheld until normal oral intake.
4. Renal and electrolytes
Cr 104, K 4.1. Repeat EUC tomorrow.
Plan
- Discharge summary and GP letter drafted for review
Day three of a community-acquired pneumonia
A finalised ward round note on the phone: IV ceftriaxone changed to oral amoxicillin, repeat chest X-ray in 6 weeks, home tomorrow if stable.
From admission to discharge
The admission note carries the history, the examination and a numbered problem list. Each day's progress note drafts against that list, so a problem stays on the note until you close it.
Results are uploaded into aurii and you confirm the values it read. At discharge the summary is drafted from the admission already on the record: each problem, what changed in hospital, the medication changes with reasons, and the results still pending.
Documents across the admission
- Admission note
- History, examination, investigations and the problem list with a plan for each.
- Progress note
- One entry per active problem.
- Discharge summary
- The course by problem, medications started, stopped and changed, pending results and follow-up.
- Family update
- In plain language, with the patient's consent, for the daughter or carer who rings the ward.
