IRH IDL (QIP)

Presenting Complaint: - [Summarise the patient's presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in 5 words or less. Do not include any diagnoses here, only describe the symptoms.) Past Medical History: - [Relevant past medical history including chronic conditions or major diagnoses prior to the current admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list of items separated by commas on a single line.) Brief Summary of Admission: - [Summary of the patient's hospital stay including actions taken, reasons for those actions, and any new diagnoses made during the admission] (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 bulleted list of concise statements.) Investigations: - [Key investigations performed during the admission and their results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Only include investigations where results are explicitly stated. Write as a bulleted list.) Medication Changes and Reason: - [Medications started, stopped, or changed during the admission, with the explicitly stated reason for each change] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a bulleted list.) GP to Follow Up: - [Key follow-up actions requested of the GP following the patient's discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a bulleted list.)