Documenting a vascular round
aurii drafts the progress note, the procedure note, the letters and the discharge summary from one spoken review.
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Spoken on the vascular round
Day two after a femoral to popliteal bypass, on a synthetic patient.
"Day two after the femoral to popliteal bypass. He is comfortable and mobilising to the chair."
"The graft is palpable in the groin, the foot is warm, and the dorsalis pedis is triphasic on the Doppler."
"The groin wound is dry with no haematoma, and the leg wound edges are clean."
"Renal function is stable, he is back on his usual antihypertensives, and the heparin infusion stopped this morning."
"Continue the antiplatelet and the statin, physiotherapy for mobilisation, and a duplex scan before discharge."
"Letter to his GP with the surveillance plan and the wound care, and a letter back to the referring physician."
Day 2 following femoral to popliteal bypass. Comfortable, mobilising to the chair.
Graft palpable in the groin. Foot warm and well perfused. Triphasic dorsalis pedis signal on Doppler. Groin wound dry with no haematoma. Leg wound edges clean.
Renal function stable. Usual antihypertensives recommenced. Heparin infusion ceased this morning.
- Continue antiplatelet and statin
- Physiotherapy for mobilisation
- Duplex scan before discharge
- GP letter with the surveillance plan and wound care
- Letter to the referring physician
Illustration of the drafting view.
Perfusion, wounds and the surveillance plan
aurii drafts the progress note from the review as it is spoken, with the pulses or Doppler signal, the foot, the wounds and the drains in comparable terms each day. The letter drafts from the same review and carries the graft, the imaging interval and the medication the patient stays on. The surgeon signs both.
Documents from one vascular round
Billing items are captured at the bedside against the episode, for your practice to claim. Billing.
Starter templates a vascular list draws on
- Procedure note (generic)
- Ward round note
- Discharge note
- GP discharge summary
- Specialist-to-specialist
Your letterhead and section order, set once, on every draft. The template set.
The letter that carries the surveillance plan
One review produces both documents. The letter names the graft, the surveillance interval, the wound care and the medication the patient stays on, and the surgeon signs it before it goes.
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