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
Tonsilitis: 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
Tonsilitis: 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.
Managing sentences No audible wheeze
Sounds stable no distress.
Managing sentences No audible wheeze
GENERALLY UNWELL
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
Phone consult: Other
GM Notes accessed:
Consult with Mother/ Father /Partner /Son/Daughter/ Carer
PMSrHx as below
TODAY:
GM Notes accessed:
Consult with Mother/ Father /Partner /Son/Daughter/ Carer
PMSrHx as below
TODAY:
Face 2 face appointment scheduled
RAEI OOH
States can get here for:
Urgent attention if any acute deterioration
(ooh 111 / a+e )
RAEI OOH
States can get here for:
Urgent attention if any acute deterioration
(ooh 111 / a+e )
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
Home visit booked
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
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: Patient
GM Notes accessed:
PMSrHx as below
TODAY:
GM Notes accessed:
PMSrHx as below
TODAY:
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
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
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
Tonsilitis: Nill obvious
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
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
Tonsilitis: Nill obvious
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
Phone consult: MEDICATION REQUESTED
Medication requested:
Reason: Ran out
Will bring in proof of medications
Aware will only be issued short quantity untill able to contact own gp for full prescription.
Controlled drugs required
Will bring in proof of meds and proof of identity
Medication requested:
Reason: Ran out
Will bring in proof of medications
Aware will only be issued short quantity untill able to contact own gp for full prescription.
Controlled drugs required
Will bring in proof of meds and proof of identity
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
Medication: ? Nill
PMSH: ? Nill
Phone consult: Patient
Amunir4695828
GM Notes accessed:
PMSrHx as below
TODAY:
Amunir4695828
GM Notes accessed:
PMSrHx as below
TODAY:
Phone consult: Other
Amunir4695828
GM Notes accessed:
Consult with Mother/ Father /Partner /Son/Daughter/ Carer
PMSrHx as below
TODAY:
Amunir4695828
GM Notes accessed:
Consult with Mother/ Father /Partner /Son/Daughter/ Carer
PMSrHx as below
TODAY: