Documenting a respiratory and sleep round
aurii drafts the progress note, the letter to the GP and the discharge summary from one spoken review.
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Spoken at the bedside
Day two of an infective exacerbation of COPD, on a synthetic patient.
"Day two of the COPD exacerbation. Breathing is easier and he slept flat overnight."
"Saturations are ninety-two on two litres, down from four litres yesterday, respiratory rate eighteen."
"Chest is still wheezy at both bases, air entry is better, no crackles, and he has been afebrile since admission."
"Sputum culture grew nothing, so stop the intravenous antibiotics and finish the oral course. Day three of prednisolone, two more days."
"Wean the oxygen as tolerated, physiotherapy review, and book the sleep study as an outpatient for the overnight desaturation."
"Letter to his GP with the discharge plan and the inhaler change."
Day 2 of an infective exacerbation of COPD. Symptomatically improved, slept flat overnight. Saturations 92% on 2 L, weaned from 4 L. Respiratory rate 18.
Expiratory wheeze at both bases with improved air entry. No crackles. Afebrile since admission.
Sputum culture no growth. Intravenous antibiotics ceased, oral course to complete. Day 3 of prednisolone, two days remaining.
- Wean oxygen as tolerated
- Physiotherapy review
- Outpatient sleep study for the overnight desaturation
- GP letter with the discharge plan and the inhaler change
Illustration of the drafting view.
The ward, the lung function room and the sleep study
aurii drafts the round note, the clinic note and the sleep review from the review as it is spoken: the oxygen and its trend, lung function against the last set, the pressure settings and the device. The GP letter drafts from the same words, so an inhaler or pressure change reaches the practice in the specialist's terms.
Documents from one ward review
Billing items are captured at the bedside against the episode, for your practice to claim. Billing.
Starter templates a respiratory service draws on
Your letterhead and section order, set once, on every draft. The template set.
The letter the GP acts on
One review produces both documents. The letter names the diagnosis, the treatment given, the device or inhaler change and the studies arranged, and the clinician signs it before it goes.
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