Documenting a haematology round

aurii drafts the treatment note, the transfusion record and the letter to the GP.

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Spoken at the chair before treatment

A pre-cycle review in the day therapy unit, synthetic patient.

Spoken in the day unit Ambient capture

"Cycle three of R-CHOP today, and she got through the last one with no fevers."

"Neutrophils one point eight, up from point four, platelets one forty, so we treat."

"Haemoglobin seventy eight and breathless, so two units before the cyclophosphamide."

"Grade two neuropathy in the fingers, so cap the vincristine at one milligram this cycle."

"Filgrastim from day four again, and the antiemetics held, so keep that schedule."

"Interim PET after cycle four, and a letter to her GP about the transfusion and the neuropathy."

Day unit treatment note Cycle 3 of R-CHOP · Demo patient · 63 · Chair 6

Ready to sign

Pre-treatment counts

Cycle 3 of R-CHOP due today. Cycle 2 completed without febrile neutropenia. Neutrophils 1.8, recovered from 0.4. Platelets 140. Counts meet the threshold to treat.

Transfusion

Haemoglobin 78 with exertional dyspnoea. Two units of packed red cells crossmatched. Transfusion before the cyclophosphamide, observations charted each unit.

Dose modification

Grade 2 peripheral neuropathy in the fingertips. Vincristine capped at 1 mg this cycle. Filgrastim from day 4. Antiemetic schedule unchanged, it held through cycle 2.

Plan

Interim PET after cycle 4
GP letter covering the transfusion and the neuropathy
Full blood count and film before the next cycle

Synthetic demo patient.

GP letterDrafted Discharge summaryQueued Billing3 items

Illustration of the drafting view.

Drafted at the chair

aurii drafts the treatment note from the review spoken at the chair: the counts that cleared the cycle, the dose against each agent, any modification and its reason. The record carries forward across the unit, the ward and the clinic, so a dose capped at cycle three is on the page at cycle four. The haematologist signs.

What one pre-cycle review produces

Draft The day unit treatment noteThe counts that cleared the cycle, the dose given against each agent, any modification with its reason, the observations through the infusion.

Draft The transfusion recordThe product, the units, the consent and the observations at each set, against the count that prompted it.

Draft The GP letterWhat was given, which agent was reduced and why, and the temperature at which the patient goes to hospital.

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

Starter templates a haematology unit uses

A haematology service works from the general starter set: the ward round note for the ward, the progress note at the chair, and the results notification for the counts.

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

Correspondence between cycles

The letter to the general practitioner drafts from the same review: the regimen and the cycle, the counts on the day, any dose reduced and why, and the temperature that means going to hospital. The haematologist signs it.

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