@\cov@ Covid session / phone / accurix / admin
@\covex@ Denies Covid exposure in last 2 weeks (friends / family / travel / tests)
@\covsy@ States no covid symptoms (New or Continuous fever, cough, sob, loss taste, loss smell)
@\covtn@ Covid test: negative
Date:
@\covtp@ Covid test: positive
Date:
@\covex@ Denies Covid exposure in last 2 weeks (friends / family / travel / tests)
@\covsy@ States no covid symptoms (New or Continuous fever, cough, sob, loss taste, loss smell)
@\covtn@ Covid test: negative
Date:
@\covtp@ Covid test: positive
Date:
@\bb@Booking reason for appt today:
@\bb1@ Test results (bloods / imaging)
@\cw@ Consult with Mother/ Father /Partner /Son/Daughter/ Carer
@\sw@ Seen with Mother/ Father /Partner /Son/Daughter/ Carer
@\ss@ See previous consults / letters / e consults /Photos
@\sgp@ Seen in GP surgery
@\hx@ Hx as below
@\tel@ Telephone Encounter
@\bb1@ Test results (bloods / imaging)
@\cw@ Consult with Mother/ Father /Partner /Son/Daughter/ Carer
@\sw@ Seen with Mother/ Father /Partner /Son/Daughter/ Carer
@\ss@ See previous consults / letters / e consults /Photos
@\sgp@ Seen in GP surgery
@\hx@ Hx as below
@\tel@ Telephone Encounter
@/tcb@ To call back as required
@/ri@ If not settled / settling
@/rs@ Sooner if required.
@/rr@ Review with results
@/ee@ Urgent attention if any acute deterioration (Here / ooh 111 / a+e )
@/ri@ If not settled / settling
@/rs@ Sooner if required.
@/rr@ Review with results
@/ee@ Urgent attention if any acute deterioration (Here / ooh 111 / a+e )
@/r1@ Review in 1 week or so
@/r2@ Review in 2 weeks or so
@/r3@ Review in 3 weeks or so
@/r4@ Review in 4 weeks or so
@/rw@ Review post weekend if symptoms not settled
@/rab@Review post abx if symptoms not settled
@/r2@ Review in 2 weeks or so
@/r3@ Review in 3 weeks or so
@/r4@ Review in 4 weeks or so
@/rw@ Review post weekend if symptoms not settled
@/rab@Review post abx if symptoms not settled
@/da@ Denies allergy.
@/pb@ No pregnancy or breast feeding
@/pb@ No pregnancy or breast feeding
@/ff@ F2f appointment agreed - will come asap
@/ffs@ F2f appt Scheduled.
@/fft@ F2f appt Needed / Tasked admin to schedule.
@/tt@ For tests / Tasked admin / Forms and instructions via Reception
@/ffs@ F2f appt Scheduled.
@/fft@ F2f appt Needed / Tasked admin to schedule.
@/tt@ For tests / Tasked admin / Forms and instructions via Reception
@/mep@ EPS to designated chemist - Safe collection arranged by patient / guardian.
@/mepa@ EPS Any chemist - Safe collection arranged by patient / guardian.
NHS number given phone/accurix
@/mepa@ EPS Any chemist - Safe collection arranged by patient / guardian.
NHS number given phone/accurix
@/med3@ Med3 completed, Via admin for collection /email/ fax.
(Reason, dates, durations discussed / e consult)
@/oh@ Occupational health assessment advised
(Reason, dates, durations discussed / e consult)
@/oh@ Occupational health assessment advised
@\acc@ Accurix sent tcb/ request photos.
@\tad@ Tasked admin
@\tad@ Tasked admin
@//hyd@
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
@\\fc@Unable to contact in person
Mobile: Unable to leave message / Message left
Landline: Nill / Unable to leave message / Message left
Call back as required GP surgery / ooh 111 /
Walk in centre
Acute deterioration 999/ A+E
Mobile: Unable to leave message / Message left
Landline: Nill / Unable to leave message / Message left
Call back as required GP surgery / ooh 111 /
Walk in centre
Acute deterioration 999/ A+E
@//psyex@Good rapport insight / Not tearful or agitated / Speech: Normal
@//psyhx@Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
@//psyhx@Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
@//nn@ No new or worsening symptoms or signs
@//nnn@ No other acute concerns symptoms or signs
@//nnn@ No other acute concerns symptoms or signs
@//bp@ BP check, monitoring required.
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90 or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist or Via Reception Appointment Practice HCA or Nurse
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90 or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist or Via Reception Appointment Practice HCA or Nurse
@//eee@
Advised urgent A+E
Ambulance as required
Otherwise taxi or transport by other
States will arrange as quickly as possible
Advised urgent A+E
Ambulance as required
Otherwise taxi or transport by other
States will arrange as quickly as possible
@//nu12@No new or progressive neurological symptoms face arms legs,
No disturbance to cognition, vision, speech.
@//nu1@No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
@//nu2@No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
@//nu3@No new functional loss
No disturbance to cognition, vision, speech.
@//nu1@No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
@//nu2@No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
@//nu3@No new functional loss
@//Men@
Fever: Nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
Fever: Nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
@//resp@
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
@/ex@ Sounds stable no distress.
@//extpp@Alert Orientated time place person
@//exr@Managing sentences No audible wheeze
@//exr1@ Managing sentences No audible wheeze No use of accessory muscles
@//extpp@Alert Orientated time place person
@//exr@Managing sentences No audible wheeze
@//exr1@ Managing sentences No audible wheeze No use of accessory muscles
@/mgp@ Script Done - Safe Collection from reception, arranged by patient / guardian.
@/rrr@ Script Done, Requests Reception send to designated chemist
@/req@Medication Request generated for script: EPS by own GP/ Admin
@/rrr@ Script Done, Requests Reception send to designated chemist
@/req@Medication Request generated for script: EPS by own GP/ Admin
@/fff@ No further face to face slots available with myself today
@/ndoc@No Docman access this session
@/nacc@ No accurix access this session
@/ndoc@No Docman access this session
@/nacc@ No accurix access this session
@//Gen@
Feels generally unwell
Travel: nill
Ill contacts: nill
Fever: nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Eyes: nad
Ears:Nose: nad
Throat soreness : nad
Rashes: Nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Increased work of breathing: nill
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Abdominal pain: Nill
Bowel Motion: Normal
Diarrhoea: Nill
pr bleed melaena: Nill
Urine output: Normal usual amounts
Vaginal: Nill lmp
Feels generally unwell
Travel: nill
Ill contacts: nill
Fever: nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Eyes: nad
Ears:Nose: nad
Throat soreness : nad
Rashes: Nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Increased work of breathing: nill
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Abdominal pain: Nill
Bowel Motion: Normal
Diarrhoea: Nill
pr bleed melaena: Nill
Urine output: Normal usual amounts
Vaginal: Nill lmp
@//expead@
Appears well
Alert
interacting
No meningism / Brudzinski negative
No irritability
Colour/Tone: Good
Moist mucous membranes
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
tracheal tug: nill recessions ics scs: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
Appears well
Alert
interacting
No meningism / Brudzinski negative
No irritability
Colour/Tone: Good
Moist mucous membranes
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
tracheal tug: nill recessions ics scs: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
@//chesty@ Chesty cough
Occasional murky sputum
Fevers: Nill / on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Occasional murky sputum
Fevers: Nill / on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
@//exad@
Appears well, stable
Alert
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Appears well, stable
Alert
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
@//sob@ Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
@//card@ Cardiac type / Exertional chest pain: nill
Palpitations: nill
@//card1@ Orthopnea: nill PND: nill
Palpitations: nill
@//card1@ Orthopnea: nill PND: nill
@//DV@
Mon v: d:
Tue v: d:
Wed v: d:
Thur v: d:
Fri v: d:
Sat v: d:
Sun v: d:
Mon v: d:
Tue v: d:
Wed v: d:
Thur v: d:
Fri v: d:
Sat v: d:
Sun v: d:
@//GABAPENT@
Morning/ Afternoon/ Evening
Stop at the level where symptoms are controlled
or if any side effects noted
1,1,1 Three to Four days
2,1,1 Three to Four days
2,1,2
2,2,2
3,2,2
3,2,3
3,3,3
Morning/ Afternoon/ Evening
Stop at the level where symptoms are controlled
or if any side effects noted
1,1,1 Three to Four days
2,1,1 Three to Four days
2,1,2
2,2,2
3,2,2
3,2,3
3,3,3
@//snmen@Safety net advise Meningitis and Scarlet fever
@//sndvt@Safety net advise DVT
@//sncard@Safety net advise Chest pains Palpitations
@//sncauda@Safety net advise Cauda Equina
@//sndvt@Safety net advise DVT
@//sncard@Safety net advise Chest pains Palpitations
@//sncauda@Safety net advise Cauda Equina
@//hyd1@
Eating and drinking: Off solids
Fluids less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: less than usual amounts
Eating and drinking: Off solids
Fluids less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: less than usual amounts
@//Xptrav@Traval: nill
Ill contacts: nill
@//Xpresp@No obvious exposure factors smoke dust pets fumes damp
@//Xpallergy@No obvious trigger factors, oral, parenteral, topical
@//Xpdiet@No obvious link to food types wheat dairy
Ill contacts: nill
@//Xpresp@No obvious exposure factors smoke dust pets fumes damp
@//Xpallergy@No obvious trigger factors, oral, parenteral, topical
@//Xpdiet@No obvious link to food types wheat dairy
//BABY
Antenatal: no problems
Delivery gestation: Term
Delivery: nvd / c section
Postnatal: no problems
Breast Feeding: y/n
Bottle feeding:y/n
Formula:
Antenatal: no problems
Delivery gestation: Term
Delivery: nvd / c section
Postnatal: no problems
Breast Feeding: y/n
Bottle feeding:y/n
Formula:
//OBS
Medical conditions/medications affecting pregnancy: Nill
Gravida:
Para:
P1 / yrs ago / nvd / c section / micarriage
Medical conditions/medications affecting pregnancy: Nill
Gravida:
Para:
P1 / yrs ago / nvd / c section / micarriage
//exNeuro
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
//exEar
Ear Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Ear Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
@//exEye@
Eye Right/ Left
Periorbital changes: nill
lid/lashes: nad
Conjunctiva: nad
Scleral inflammation: nill
PERLA
EOM Full rom
Photophobia: nill
Opthalmoscopy : nad
va: without glasses
r: 6/6 l: 6/6
Other Eye - nad
Eye Right/ Left
Periorbital changes: nill
lid/lashes: nad
Conjunctiva: nad
Scleral inflammation: nill
PERLA
EOM Full rom
Photophobia: nill
Opthalmoscopy : nad
va: without glasses
r: 6/6 l: 6/6
Other Eye - nad
@//pill@
BMI: Good (< 35)
BP: Good (<145 systolic)
Smoker: Nill
No hx/fhx: Migraines with auras
No hx/fhx: CHD / CVD events
No hx/fhx: Thromboembolic events dvt/pe
No hx/fhx: Breast cancers/ gynaecological cancers
No hx/fhx: Cervical cancers/ abnormal smears
No hx/fhx: Liver or renal impairement
No enzyme inducing medication
BMI: Good (< 35)
BP: Good (<145 systolic)
Smoker: Nill
No hx/fhx: Migraines with auras
No hx/fhx: CHD / CVD events
No hx/fhx: Thromboembolic events dvt/pe
No hx/fhx: Breast cancers/ gynaecological cancers
No hx/fhx: Cervical cancers/ abnormal smears
No hx/fhx: Liver or renal impairement
No enzyme inducing medication
@//pill1@
Current pill:
Happy on it
wants to continue
Current pill:
Happy on it
wants to continue
@//pill2@
Current pill:
Side efefcts noted
Try change to:
Current pill:
Side efefcts noted
Try change to:
@//pill3@
Combined pill contraindicated:
Discussed progesterone only methods
minipill
depot injection
implant
coils
Combined pill contraindicated:
Discussed progesterone only methods
minipill
depot injection
implant
coils
@//exobs@
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear