Paramedic Patient Clinical Assessment Note

Global Overview: [Overview of how entry was gained, where the patient was found, their position and general appearance, who else was present, where the call originated from and any immediate safety concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) Presenting Complaint (PC): [Patient's main presenting symptom or symptoms and duration of the current issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write concisely and keep symptom-focused. Do not include direct patient quotes.) History of Presenting Complaint (HPC): [Chronological account of symptoms including onset, duration, progression, nature, severity, associated symptoms, exacerbating and relieving factors, timing and any previous episodes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Include patient-reported information only. Do not include examination findings or clinical interpretation. Write in paragraphs of full sentences.) Past Medical History: [Previous medical conditions ordered by clinical relevance to the presenting complaint, including date of diagnosis or relevant timeframe where stated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use standard medical abbreviations where appropriate. Do not include current symptoms, medications or clinical interpretation. Write as a comma-separated list on a single line.) On Examination (OE): [Objective examination findings including general appearance and relevant system examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Exclude patient-reported symptoms. Write in paragraphs of full sentences.) Cranial Nerve Assessment: (Only include if a cranial nerve assessment or neurological examination is explicitly undertaken in transcript, contextual notes or clinical note, else omit section entirely. List each cranial nerve individually. If a nerve is not assessed, document as "NOT CHECKED". If a reason is provided for omission, document in lower case as "not checked: [reason]". Do not infer or complete missing findings.) CN I (Olfactory): [Olfactory nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN II (Optic): [Optic nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN III (Oculomotor): [Oculomotor nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN IV (Trochlear): [Trochlear nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN V (Trigeminal): [Trigeminal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN VI (Abducens): [Abducens nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN VII (Facial): [Facial nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN VIII (Vestibulocochlear): [Vestibulocochlear nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN IX (Glossopharyngeal): [Glossopharyngeal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN X (Vagus): [Vagus nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN XI (Accessory): [Accessory nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) CN XII (Hypoglossal): [Hypoglossal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) DANISH Assessment: (Only include if dizziness or vertigo is reported or a cranial nerve or neurological assessment is undertaken in transcript, contextual notes or clinical note, else omit section entirely. If a reason is provided for any omission, document the reason.) D – Dysdiadochokinesis: [Dysdiadochokinesis assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) A – Ataxia (gait/coordination): [Ataxia and gait or coordination assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) N – Nystagmus: [Nystagmus assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) I – Intention tremor: [Intention tremor assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) S – Speech (dysarthria): [Speech and dysarthria assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) H – Head impulse test (HIT): [Head impulse test findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".) Observations: Initial Observations — [Time of initial observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.): Heart Rate (HR): [Heart rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Blood Pressure (BP): [Blood pressure value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Respiratory Rate (RR): [Respiratory rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Oxygen Saturations (SpO₂): [Oxygen saturation value and percentage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Temperature (Temp): [Temperature value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Capillary Refill Time (CRT): [Capillary refill time value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Level of Consciousness (GCS/AVPU): [Level of consciousness using GCS or AVPU scale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) End Tidal CO₂: [End tidal CO₂ value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Pulse Character: [Pulse character description] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) ECG Rhythm: [ECG rhythm findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Pupils (size and reactivity): [Pupil size and reactivity findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Repeat Observations — [Time of repeat observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.): Heart Rate (HR): [Heart rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Blood Pressure (BP): [Blood pressure value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Respiratory Rate (RR): [Respiratory rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Oxygen Saturations (SpO₂): [Oxygen saturation value and percentage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Temperature (Temp): [Temperature value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Capillary Refill Time (CRT): [Capillary refill time value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Level of Consciousness (GCS/AVPU): [Level of consciousness using GCS or AVPU scale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) End Tidal CO₂: [End tidal CO₂ value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Pulse Character: [Pulse character description] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) ECG Rhythm: [ECG rhythm findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Pupils (size and reactivity): [Pupil size and reactivity findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) (Repeat this observations block for each additional set of observations documented.) Blood Results: [Blood investigation results documented without clinical interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Urinalysis: (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Leukocytes: [Leukocytes result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Nitrates: [Nitrates result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Urobilinogen: [Urobilinogen result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Protein: [Protein result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) pH: [Urinary pH result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Haematuria: [Haematuria result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Specific Gravity: [Specific gravity result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Ketones: [Ketones result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Bilirubin: [Bilirubin result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Glucose: [Urinary glucose result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.) Medication History (MHx): [Current medications including name, dose, frequency, compliance and any recent changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use standard medication abbreviations where appropriate. Write as a list.) Allergies: [Known allergies and the type of reaction associated with each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no known drug allergies are explicitly stated, write: "NKDA".) Family History (FHx): [Relevant family medical history including relationship to patient and condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Social History (SHx): [Relevant social history including smoking status, alcohol and drug use, occupation, living situation and baseline level of function] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Working Diagnosis: [Clinician's explicitly stated working diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write concisely without rationale.) Differential Diagnosis: [Clinician's explicitly stated differential diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a bullet point list without rationale.) Plan: [Management plan including investigations ordered, treatments prescribed, follow-up arrangements and patient education] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) Decision Making Rationale: [Rationale for the working diagnosis and management plan including supporting and contradicting factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write each point with supporting and contradicting factors as bullet points.) Worsening / Recontact Advice: [Worsening, safety netting or recontact advice given to the patient, their friends, relatives or carers] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) Clinical Discussions / Advice Sought: [Summary of any conversations with other clinicians regarding patient care, including the reason for the discussion, the outcome, and the full name, role and organisation of the person consulted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in the first person in paragraphs of full sentences.)