<aside> 💡 The following is a helpful template to aid clerking on the medical take.
You can copy and paste the template from the top right hand corner when clerking and keep it saved in the “Clinical Summary” on Nerve Centre.
NOTE: It may not be comprehensive!
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**MEDICAL CLERKING IN PROGRESS**
PC:
BG:
DNA CPR status:
ISSUES:
1)
PMH:
-
DH:
[Get list from patient and SCR on Lorenzo]
Allergies:
SH & FH:
-
O/E:
NEWS:
General: incl. GCS/AVPU
Respiratory:
Cardio:
Abdo:
Calves:
Neuro:
INVESTIGATIONS:
- Bloods:
- CXR:
- VBG:
- ECG:
IMPRESSION / CLINICAL SUMMARY:
MEDICATION ALREADY RECIEVED IN ED/AMBULANCE/GP/HOME:
-
PLAN:
1) VTE form + prescribing
2) TEP & RESPECT Forms complete
3) Clerk medications into Lorenzo