Resident Template

IRH IDL (QIP)

A professional Resident template for healthcare professionals.

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Specialty

Resident

Used

9 times

Type

Note

Last edited

1/4/2026

Created by

Struan Hogg

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About this template

Streamline your hospital discharge summaries with this essential IRH IDL (QIP) template, perfect for busy Residents and junior doctors. This template is expertly designed to capture all critical information from a patient's admission, focusing on clarity and consistency. Easily summarise presenting complaints, relevant past medical history, key decisions made during admission, and crucial investigation results. The template also ensures a comprehensive record of all medication changes and outlines clear follow-up actions for the patient's GP. With Heidi, this template dynamically pulls information from your consultation transcript, ensuring every detail, from acute cholecystitis management to post-operative care, is accurately and consistently documented, saving you valuable time and enhancing patient safety.

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IRH IDL (QIP) Presenting Complaint: Acute onset abdominal pain Past Medical History: Hypertension, Type 2 Diabetes Mellitus, Dyslipidaemia, GORD Brief Summary of Admission: * Patient admitted with acute cholecystitis, confirmed by abdominal ultrasound. * Laparoscopic cholecystectomy performed due to persistent pain and inflammation. * Post-operative recovery was uncomplicated, patient tolerated oral intake well. * Discharged with advice on wound care and pain management. Investigations: * Full Blood Count: WBC 14.5 x 10^9/L (elevated), Neutrophils 12.1 x 10^9/L (elevated) * Liver Function Tests: ALT 120 U/L (elevated), AST 105 U/L (elevated), ALP 180 U/L (elevated), GGT 210 U/L (elevated), Bilirubin Total 2.5 mg/dL (elevated) * Abdominal Ultrasound: Gallbladder wall thickening (4mm), pericholecystic fluid, gallstones present (largest 1.5 cm) * ECG: Normal Sinus Rhythm Medication Changes and Reason: * Ceftriaxone 1g IV daily: Started for treatment of acute cholecystitis. * Metronidazole 500mg IV three times daily: Started for treatment of acute cholecystitis. * Paracetamol 1g oral four times daily: Started for post-operative pain relief. * Diclofenac 50mg oral three times daily: Started for post-operative pain relief. * Omeprazole 20mg oral daily: Continued for GORD management. * Lisinopril 10mg oral daily: Continued for hypertension management. * Metformin 500mg oral twice daily: Continued for Type 2 Diabetes Mellitus management. GP to Follow Up: * Remove sutures in 7-10 days. * Monitor blood pressure and blood glucose levels. * Review post-operative pain control and wound healing. * Continue current medications as prescribed. * Advise on dietary modifications post-cholecystectomy.