Anaesthetist Template

Prépique

A professional Anaesthetist template for healthcare professionals.

About this template

Looking for a streamlined way to document pre-operative assessments? The 'Prépique' template is designed for anaesthetists and provides a structured format for capturing essential patient information. This template helps you efficiently record subjective complaints, medical history, medications, objective findings, assessment, and the anaesthetic plan. With Heidi, this template can be automatically populated from your clinical conversations, saving you time and ensuring comprehensive documentation. Simplify your pre-operative note-taking and focus on what matters most: your patients.

Preview template

Subjective: The patient presents for a pre-operative assessment prior to a scheduled elective laparoscopic cholecystectomy. The patient reports experiencing intermittent right upper quadrant pain, particularly after consuming fatty foods, for the past six months. The patient denies any fever, chills, or jaundice. The patient states they are anxious about the surgery and would like to discuss pain management options. Past Medical History: The patient has a history of hypertension, well-controlled with medication. They had a previous uncomplicated appendectomy at age 10. Medications - Lisinopril 10mg daily - Paracetamol as needed for pain - No known drug allergies. Objective: Blood pressure: 130/80 mmHg, Heart rate: 78 bpm, Respiratory rate: 16 breaths/min, Oxygen saturation: 98% on room air. The patient is alert and oriented. Cardiovascular examination reveals a regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory examination is clear to auscultation bilaterally. Abdomen is soft, non-tender to palpation except for mild tenderness in the right upper quadrant. No guarding or rebound tenderness is present. Assessment: The patient is a 55-year-old female presenting for pre-operative assessment prior to laparoscopic cholecystectomy. The patient has symptomatic cholelithiasis. The patient's hypertension is well-controlled. ASA physical status classification: II. Plan: - Discussed the surgical procedure, risks, and benefits with the patient. - Discussed anaesthetic plan including general anaesthesia with regional analgesia. - Ordered pre-operative blood tests (FBC, U&Es, LFTs, clotting screen). - Prescribed pre-operative medications: Ondansetron 4mg IV and Ranitidine 50mg IV. - Instructed the patient to fast from midnight the night before surgery. - Scheduled the patient for surgery on 1 November 2024. - Provided the patient with information regarding post-operative pain management.

Subjective: [describe current issues including reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document past medical history, previous surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Medications - [mention medications including OTC supplements and any allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as list.) Objective: [document physical examination findings, vital signs, and relevant objective observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Assessment: [provide a diagnostic impression or summary of the patient's condition based on subjective and objective data] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: [outline the proposed treatment plan, including investigations, referrals, medications, and follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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