Patient Information:
- Patient Name: John Smith
- Family/whanau present at the meeting: Wife, Mary Smith
- Location: Hospital room
Assessment:
Pain:
- Provocation: Worse with movement, better with rest. Quality: Sharp, stabbing. Region: Right flank. Severity: 7/10. Timing: Constant, with exacerbations.
Medications:
- Morphine, 10mg IV q4h. Side effects: Constipation.
Elimination:
- Bowels open size: Small.
- Bowel type: Hard.
- Bladder output: 200ml, toilet.
- Nausea or vomiting: None.
Sleep:
- Quality of sleep: Poor, restless sleep, 4 hours.
- Sleep location: Bed.
- Medications or sedatives: Zopiclone 7.5mg at night.
Social:
- Family staying to support: Wife, Mary Smith, providing emotional support and assistance with personal care.
- Family education of medications: Syringe driver education provided to wife.
- Reason for visit/admission, including patient’s verbalized concerns or symptoms: Admitted for pain management related to metastatic cancer. Patient expresses concerns about pain control and end-of-life care.
- Any expressed concerns about treatment, care, or the healthcare environment: Patient expresses concerns about pain control and end-of-life care.
- Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs: Patient and wife understand the diagnosis and treatment plan, including palliative care goals.
Objective:
- Vitals: BP 130/80, HR 88, RR 18, Temp 37.0, Oxygen Saturation 96% on room air.
- Physical assessment findings: Patient appears weak and fatigued. Skin integrity intact. No edema. Lung sounds clear. Abdomen soft, with tenderness in the right flank. Mobility status: Ambulatory with assistance.
- Prioritization of patient care needs: Pain management, symptom control, and emotional support.
Future planning:
- Ceiling of care: Full resuscitation, antibiotics as needed.
- Burial or cremation: Discussed with patient and wife. Dr. Emily Carter to complete paperwork.
Interventions + Evaluations:
- Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc.: Administered Morphine as prescribed. Provided pain assessment and reassessment. Educated patient and wife on pain management strategies and side effect management. Coordinated with the palliative care team.
- Response to interventions: Patient reports some relief from pain after Morphine administration.
- Evaluation of patient’s response to interventions and progress towards care goals: Pain levels decreased from 9/10 to 7/10. Patient appears more comfortable.
- Any changes in patient status or findings: Patient's pain level improved slightly.
Additional Notes:
- Any patient or family education provided, including discharge planning or instructions for home care: Educated patient and wife on pain management, medication side effects, and advance care planning. Provided information on community resources.
- Communication with patient and family about care decisions, concerns, and preferences: Discussed patient's wishes regarding end-of-life care and advance directives with the patient and wife.
- Any safety concerns or incidents reported: None.
Plan for Continuing Care:
- Next steps in patient’s care plan, including any planned adjustments to interventions, additional tests or procedures, follow-up needs, etc.: Continue pain management. Monitor for side effects. Schedule follow-up with palliative care team.
- Care plan adjustments or interventions planned for the shift, including medication administration, wound care, mobility assistance, patient education, etc.: Administer Morphine as prescribed. Continue to assess pain levels. Provide emotional support.
- Scheduled procedures or tests for the day: None.
- Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.): Discussed patient's case with the palliative care physician and social worker.
Patient Information:
- [Patient Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [family/whanau present at the meeting] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Location (e.g., phone call, home visit)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
Pain:
- [Provocation (what makes it worse/better), quality (what the pain feels like, throbbing, sharp, dull), region (location of the pain, spread of the pain), Severity (how intense is the pain 1-10) timing (when does the pain occur and how long does it last)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications:
- [name, time and dose of medication (e.g., Morphine, 10mg BD)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [side effects of medications (e.g: constipation or nausea)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Elimination:
- [bowels open size (e.g., small, med, large)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [bowel type (soft, hard)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [bladder output (amount, toilet, IDC)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [nausea or vomiting] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sleep:
- [quality of sleep (length and quality of sleep)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [sleep location (e.g., bed, lazy boy)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [medications or sedatives (e.g., zopiclone, magnesium)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social:
- [family staying to support (name of family and number caring for patient)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [family education of medications (syringe driver, oral medications and type of route of medications)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Reason for visit/admission, including patient’s verbalized concerns or symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any expressed concerns about treatment, care, or the healthcare environment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective:
- [Vitals including BP, HR, RR, Temperature, Oxygen Saturation, etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Physical assessment findings, including general appearance, skin integrity, presence of edema, heart and lung sounds, abdominal assessment, mobility status, and any other relevant clinical signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Prioritization of patient care needs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Future planning:
- [ceiling of care (resus status, use of antibiotics)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [burial or cremation (and name of Doctor to complete paper work)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Interventions + Evaluations:
- [Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Response to interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Evaluation of patient’s response to interventions and progress towards care goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any changes in patient status or findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Additional Notes:
- [Any patient or family education provided, including discharge planning or instructions for home care] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Communication with patient and family about care decisions, concerns, and preferences] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any safety concerns or incidents reported] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan for Continuing Care:
- [Next steps in patient’s care plan, including any planned adjustments to interventions, additional tests or procedures, follow-up needs, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Care plan adjustments or interventions planned for the shift, including medication administration, wound care, mobility assistance, patient education, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Scheduled procedures or tests for the day] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(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 include 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.)
