Denies allergy.
No pregnancy or breast feeding
No pregnancy or breast feeding
HYDRATION
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
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
PSYCHIATRIC
Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
Good rapport insight / Not tearful or agitated / Speech: Normal
Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
Good rapport insight / Not tearful or agitated / Speech: Normal
PROGRESSION / OTHER
No new or worsening symptoms or signs
No other acute concern's symptoms or signs
No new or worsening symptoms or signs
No other acute concern's symptoms or signs
BLOOD PRESSURE
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
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
NEUROLOGY
No new or progressive neurological symptoms face arms legs,
No disturbance to cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
No new or progressive neurological symptoms face arms legs,
No disturbance to cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
Meningitis check
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
RESPIRATORY
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Phone Exam
Sounds stable no distress.
Sounds stable no distress.
FACE 2 FACE
GM Notes Checked:
Seen with
GM Notes Checked:
Seen with
PHONE ADVICE: URGENT A+E
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
Neuro exam
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
Ear exam
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
Eye exam
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
Phone Exam
Alert and orientated time place person
Agitation: nill
Alert and orientated time place person
Agitation: nill
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:
OBSTETRIC
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
Phone consult:
GM Notes Checked:
Consult with
GM Notes Checked:
Consult with
HYDRATION LOW
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
RESPIRATORY Adult
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
CARDIAC
Cardiac type / Exertional chest pain: nill
Plapitations: nill
Orthopnea: nill PND: nill
Cardiac type / Exertional chest pain: nill
Plapitations: nill
Orthopnea: nill PND: nill
Feverish/ 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 / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Eating and drinking:
Normal/ less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal/ less than usual amounts
No dysuria
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 / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Eating and drinking:
Normal/ less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal/ less than usual amounts
No dysuria
Covid session / phone / accurix / admin
Denies Covid exposure in last 2 weeks (friends / family / travel / tests)
States no covid symptoms (New or Continuous fever, cough, sob, loss taste, loss smell)
Covid test: negative Date:
Covid test: positive Date:
Denies Covid exposure in last 2 weeks (friends / family / travel / tests)
States no covid symptoms (New or Continuous fever, cough, sob, loss taste, loss smell)
Covid test: negative Date:
Covid test: positive Date:
Review in 1 week or so
Review in 2 weeks or so
Review in 3 weeks or so
Review in 4 weeks or so
Review post weekend if symptoms not settled
Review post abx if symptoms not settled
Review in 2 weeks or so
Review in 3 weeks or so
Review in 4 weeks or so
Review post weekend if symptoms not settled
Review post abx if symptoms not settled
EXAM PEAD FULL
Appears Stable
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 Stable
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
EXAM ADULT QUICK
Appears stable
Alert
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
Appears stable
Alert
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
@//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
@//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
EXAM OBS
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
Face 2 Face Safety net
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
TODAY:
Medication: ? Nill
PMSH: ? Nill
TODAY:
FACE 2 FACE
GM Notes Checked:
GM Notes Checked:
Phone consult:
GM Notes Checked:
GM Notes Checked:
Phone Exam
Sounds stable no distress.
Alert and orientated time place person
Managing sentences No audible wheeze
Sounds stable no distress.
Alert and orientated time place person
Managing sentences No audible wheeze
RESPIRATORY Adult asthma / copd
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd:yes
Inhalers: yes
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd:yes
Inhalers: yes
e+d: ok
n+v: nill
RESPIRATORY Peadiatric
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
Exposure factors: Dust/mold/pets/smoke
PHARMACISTS
Discussed available chemists at this time
Prefers to collect at usual chemist when open
Discussed available chemists at this time
Prefers to collect at usual chemist when open
Phone Exam
Sounds stable no distress.
Managing sentences No audible wheeze
Sounds stable no distress.
Managing sentences No audible wheeze
F2F Appointment needed (routine / urgent )
Patient will ring Extended access hub / own gp surgery / or ooh 111
Patient will ring Extended access hub / own gp surgery / or ooh 111
RESPIRATORY Peadiatric asthma / copd
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:yes
Inhalers: yes
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:yes
Inhalers: yes
e+d: ok
n+v: nill
EXAM ADULT FULL
Appears stable
Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Appears stable
Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
EXAM PEAD QUICK
Appears Stable Alert
No meningism / Brudzinski negative
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 Stable Alert
No meningism / Brudzinski negative
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
Safety net advice:
Meningitis / scarlet fever
Discussed signs of respiratory distress
Meningitis / scarlet fever
Discussed signs of respiratory distress
? DNA:
>>>>> ? DNA >>> Reschedule / OOH 111/ A+E
>>>>> ? DNA >>> Reschedule / OOH 111/ A+E
EXAM ADULT QUICK:RESP
Appears stable
Alert
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
Appears stable
Alert
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
EXAM ADULT QUICK: Meningitis
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
wheeze /crackles: nill
F2F ADVICE: URGENT A+E
Advised urgent A+E
Letter given
Has Transport/ Taxi
States will attend as quickly as possible
Advised urgent A+E
Letter given
Has Transport/ Taxi
States will attend as quickly as possible
Cough cold last week or so
Flu like illness last week or so
Flu like illness last week or so
Likely viral illness
Liase with chemist
OTC Cough cold meds
Liase with chemist
OTC Cough cold meds
Face 2 Face Safety net
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
5min |
15min |
60min |
4 |
12 |
48 |
5 |
15 |
60 |
6 |
18 |
72 |
7 |
21 |
84 |
8 |
24 |
96 |
9 |
27 |
108 |
10 |
30 |
120 |
EAR EXAM :
Appears stable Alert
No meningism / Brudzinski: Negative
Apyrexial
t:
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
Appears stable Alert
No meningism / Brudzinski: Negative
Apyrexial
t:
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
Neuro exam
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
Eye exam
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