Edit the text below
<p>Please edit the text in the box to reflect your clinical history and examination. <br /><span style="color: yellow;"><b>NOTE: Use Shift + Enter to create a new line for correct line spacing.</b></span></p>
<p>The templates (links on the right) can be used to help produce comprehensive documentation. The text will revert back to default on a page refresh.</p>
Use the buttons to add/remove sections and Shift+Enter for new lines
Pertinent negatives [ ← Pertinent negatives template ] – No chest pain – No SOB – No dizziness
– No abdominal pain- No dyspepsia or reflux – No dysphagia – No vomiting – No haematemesis – No melaena – No change in bowel habit – No PR blood
– No weight loss – No bone pain – No night sweats – No lymphadenopathy – No fatigue – No recurrent infections
– No jaundice – No bruising/bleeding – No epistaxis – No haemoptysis – No haematuria – No haemoglobinopathies
– No menorrhagia – No IMB – No PCB – No dyspareunia
Further history [ ← Further history template ] - Past Medical History - No significant past medical history
- Family History - No significant family history
- Medication history and allergies as documented in clinical notes
- Recreational drugs - Non-smoker - No alcohol - No recreational drugs
- Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
- HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ] - No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy - CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
- Calves soft non-tender no DVT, no SOA
- Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
- Abdo: Soft non-tender - No masses / LKKSB, BS normal
Assessment [ ← Diagnostic Time-Out - consider what else could this be? ] - Impression:
Safety netting[ ← Safety netting template ] – Discussed and advised to observe for specific red flags – progressive dyspepsia or dysphagia – abdominal mass or lymphadenopathy – fever – night sweats – bone pain – weight loss – change in bowel habit – rectal bleeding – haematuria – abnormal vaginal bleeding – Understands to call or seek immediate medical review if any concerns
Copy and paste text into the notesUse windows short cuts to select the text (Ctrl + A), copy (Ctrl + C), and paste (Ctrl + V) into the clinical notes. <br><span style="color: yellow;"><b>If your clinical system is pasting the links use Ctrl+Shift+V (or Ctrl+V then press Ctrl button again and use T to select text only).</b></span>
Edit the text below
<p>Please edit the text in the box to reflect your clinical history and examination. <br /><span style="color: yellow;"><b>NOTE: Use Shift + Enter to create a new line for correct line spacing.</b></span></p>
<p>The templates (links on the right) can be used to help produce comprehensive documentation. The text will revert back to default on a page refresh.</p>
Use the buttons to add/remove sections and Shift+Enter for new lines
Pertinent negatives [ ← Pertinent negatives template ] – No chest pain – No SOB – No dizziness
– No abdominal pain- No dyspepsia or reflux – No dysphagia – No vomiting – No haematemesis – No melaena – No change in bowel habit – No PR blood
– No weight loss – No bone pain – No night sweats – No lymphadenopathy – No fatigue – No recurrent infections
– No jaundice – No bruising/bleeding – No epistaxis – No haemoptysis – No haematuria – No haemoglobinopathies
Further history [ ← Further history template ] - Past Medical History - No significant past medical history
- Family History - No significant family history
- Medication history and allergies as documented in clinical notes
- Recreational drugs - Non-smoker - No alcohol - No recreational drugs
- Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
- HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ] - No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy - CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
- Calves soft non-tender no DVT, no SOA
- Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
- Abdo: Soft non-tender - No masses / LKKSB, BS normal
Assessment [ ← Diagnostic Time-Out - consider what else could this be? ] - Impression:
Safety netting[ ← Safety netting template ] – Discussed and advised to observe for specific red flags – progressive dyspepsia or dysphagia – abdominal mass or lymphadenopathy – fever – night sweats – bone pain – weight loss – change in bowel habit – rectal bleeding – haematuria – Understands to call or seek immediate medical review if any concerns
Copy and paste text into the notesUse windows short cuts to select the text (Ctrl + A), copy (Ctrl + C), and paste (Ctrl + V) into the clinical notes. <br><span style="color: yellow;"><b>If your clinical system is pasting the links use Ctrl+Shift+V (or Ctrl+V then press Ctrl button again and use T to select text only).</b></span>
QuickNote = an easily edited standardised text for clinical notes (aka shortcut, template, boilerplate, etc)
This area will eventually contain the best and most used QuickNotes for clinical documentation from the community.
Please use the feedback button to share your most used personal QuickNotes. I will then collate and categorise these into an easy to access repository for everyone.
Particularly useful would be your standard documentation for common drugs and management scenarios. Thanks.
Please share your most useful, time-saving consultation QuickNotes in the comments section below. Colleagues can vote for the ones they like and I will convert the favourites to editable QuickNotes below for the benefit of the whole community.
Coming Soon!
This area will eventually be a place to share community-recommended files and pathways.
Please use the feedback button at the end of the page to submit your suggestions and load any files so we can all benefit from them.
An important resource for the future will be easy to use clinical pathways - we require colleagues who have expertise/experience in various specialties to help - if you would like to volunteer or share an existing pathway - please get in touch!
Please share useful links, files, and clinical pathways below via the ProductiveMedic community google drive or in the comments section. You can add files directly to the relevant folder in the google drive if you have a google account.
