Specialised Nurse Template

Symptom Management Plan

A professional Specialised Nurse template for healthcare professionals.

About this template

Effectively manage chronic conditions with the Symptom Management Plan template, designed for clear and concise clinical documentation. This invaluable tool helps healthcare professionals, particularly specialised nurses and other allied health practitioners, to meticulously detail a patient's current symptoms, functional impact, and the comprehensive strategy for their management. From medication adjustments and specialist referrals to patient education and follow-up plans, this template ensures every aspect of care is meticulously recorded. Utilise this clinical notes template to streamline your workflow and provide exceptional, well-documented patient care. Heidi's AI medical scribe automatically populates this template from your patient consultations, capturing all crucial information with precision, making your documentation process seamless and efficient.

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Specialised Nurse **Management Plan Summary:** 1. Medication Changes: Gabapentin increased to 300mg three times daily. New prescription for Fluoxetine 20mg once daily initiated. Pending approval for Botox injections for chronic migraine. 2. Paraclinical Investigations: Referral for a comprehensive sleep study and an MRI of the brain to rule out structural causes for neurological symptoms. 3. Specialist Referrals: Referral to Neurology for further assessment of chronic migraine and peripheral neuropathy, and to Pain Management for interventional pain strategies. 4. Review Interval: Follow-up scheduled in 4 weeks for medication review and assessment of new symptoms. Subsequent review in 3 months with Neurology. **Diagnosis:** Chronic Migraine with Aura (G43.109), Peripheral Neuropathy (G62.9), and Generalised Anxiety Disorder (F41.1). **Current Disease Modifying Treatment:** Patient is currently on Topiramate 100mg twice daily for migraine prophylaxis, with good adherence reported. However, breakthrough migraines remain frequent. **Current Symptoms:** Primary reason for visit is persistent severe headaches and progressive numbness and tingling in the extremities. * **Headaches:** Patient reports daily headaches for the past 3 months, described as throbbing, unilateral, and associated with visual aura, photophobia, and phonophobia. Severity is rated 7/10 on average, significantly impacting her ability to work and perform daily tasks. * **Numbness and Tingling:** Gradual onset over the past 6 months, affecting both hands and feet symmetrically. Described as pins and needles, occasional burning sensation, worse at night. Impacting fine motor skills and balance. * **Anxiety:** Reports constant worry, difficulty concentrating, and restless sleep for the past year, exacerbated by chronic pain. **Functional Impact:** Symptoms significantly impair the patient's activities of daily living, including difficulty with self-care tasks (e.g., buttoning clothes), impaired mobility due to balance issues, and reduced work productivity due to headache severity and anxiety. Quality of life is significantly diminished. **Current Medications:** * Topiramate 100mg BID * Sumatriptan 50mg PRN for acute migraines (uses 2-3 times per week) * Paracetamol 500mg PRN * Ibuprofen 400mg PRN **Physical Examination:** Vital signs stable: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Cranial nerves intact. Motor strength 4/5 in bilateral distal upper and lower extremities. Diminished sensation to light touch and pinprick in a stocking-glove distribution. Reflexes 1+ symmetrically in upper and lower extremities. Romberg's test negative, but gait is slightly unsteady with a widened base. Cognitive assessment reveals mild difficulty with concentration. **Assessment:** Patient presents with chronic, refractory migraines and progressive peripheral neuropathy, likely complicated by generalised anxiety. Symptoms are causing significant functional impairment and distress. The current management plan needs escalation and diversification to improve symptom control and quality of life. **Symptom Management Plan:** * Gabapentin 300mg three times daily (increased from 100mg BID) for neuropathic pain. * Fluoxetine 20mg once daily for generalised anxiety and potential neuropathic pain modulation. * Botox injections for chronic migraine (pending approval). **Specialist Referrals:** * Neurology for advanced migraine management and workup of peripheral neuropathy. * Pain Management Clinic for interventional pain strategies. **Patient Education:** Provided education on new medications (Gabapentin: potential for drowsiness; Fluoxetine: importance of consistent use, potential side effects). Discussed migraine triggers and non-pharmacological management strategies (stress reduction, sleep hygiene). Directed to the Migraine Trust website for additional resources and support groups. **Follow-up Plan:** Scheduled follow-up with the Specialised Nurse in 4 weeks (1 November 2024) to assess response to medication changes and ongoing symptom severity. Review of MRI and sleep study results will occur at this appointment. Patient encouraged to keep a headache diary.

**Management Plan Summary:** (Only include if a management plan is mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Summarise the key components of the management plan as a numbered list.) 1. Medication Changes: [summary of medication changes including new prescriptions, adjustments, and any pending approvals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line item.) 2. Paraclinical Investigations: [summary of any planned tests, laboratories, or imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line item.) 3. Specialist Referrals: [summary of all specialist referrals made] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line item.) 4. Review Interval: [summary of the follow-up plan including timelines and type of review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line item.) **Diagnosis:** [specific diagnosis including type and classification as stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraph format.) **Current Disease Modifying Treatment:** [current disease-modifying therapy with dosage and adherence information] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Current Symptoms:** [primary reason for visit related to symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [detailed description of current symptoms including onset, duration, severity, and impact on daily activities across relevant symptom domains] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) **Functional Impact:** [description of how symptoms affect activities of daily living, work, mobility, and quality of life] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Current Medications:** [list of current disease-modifying therapies and symptom management medications with dosages] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) **Physical Examination:** [relevant examination findings including vital signs, functional assessment scores, motor strength, reflexes, coordination, sensation, gait, and cognitive assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Assessment:** [clinical assessment of current status and symptom severity] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraph format.) **Symptom Management Plan:** [specific medications prescribed or adjusted for symptom control] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) **Specialist Referrals:** [referrals to relevant specialist services] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) **Patient Education:** [education provided regarding symptoms, medication management, lifestyle modifications, and direction to relevant resources] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Follow-up Plan:** [scheduled follow-up appointments and monitoring instructions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.)

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Specialty

Specialised Nurse

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Type

Document

Last edited

2/12/2026

Created by

Sarah Hughes

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Symptom Management Plan

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Symptom Management Plan

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