Respiratory Therapist Template

Respiratory Clinic Consultation Summary (General)

A professional Respiratory Therapist template for healthcare professionals.

About this template

Streamline your respiratory patient documentation with our comprehensive 'J Shrestha new' template, specifically designed for Respiratory Therapists and other pulmonology specialists. This clinical note template is perfect for capturing essential patient information, from presenting complaints and detailed medical histories to drug regimens and social factors impacting respiratory health. Easily summarise investigations like spirometry and radiology results, and document systemic enquiries and treatment plans. With Heidi, our AI medical scribe, this template efficiently organises complex patient data, ensuring accurate and thorough records for conditions such as asthma, COPD, and other respiratory ailments. Enhance your clinical workflow and maintain meticulous documentation with this invaluable tool for respiratory care.

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Specialty: Respiratory Therapist Presenting Complaint: - Patient presents with worsening shortness of breath and a persistent cough for the past two weeks. History of Presenting Complaint: - Patient reports a gradual onset of dyspnoea, initially mild, which has progressed to significant exertional breathlessness. Cough is productive of clear sputum, more pronounced in the mornings. No associated fever or chest pain. Symptoms are worse in the evenings and upon exposure to cold air. Current Problems: - Chronic Obstructive Pulmonary Disease (COPD) exacerbation. - 1 hospital admission in the past 12 months for COPD. - 2 exacerbations in the past 12 months requiring steroids. Past Medical History: - Diagnosed with COPD 10 years ago. Uses salbutamol inhaler PRN. No known allergies. Uses a home nebuliser for bronchodilator therapy twice daily. Drug History: - Salbutamol inhaler (2 puffs PRN) - Tiotropium bromide inhaler (1 inhalation OD) - Budesonide/formoterol inhaler (2 puffs BD) - Multivitamin supplement (1 tablet OD) Social History: - Former smoker (quit 5 years ago, 30 pack-year history). - Reports no damp or mould at home. - Retired coal miner (worked for 40 years). - Sedentary lifestyle, light walking occasionally. - Owns a cat. Number of Courses of Steroids in the Last Year (if asthma or COPD): - 2 courses of oral steroids in the last year. Summary of Investigations: - Lung function/spirometry results: FEV1 45% predicted, FVC 65% predicted, FEV1/FVC ratio 55% (consistent with severe obstruction). - FeNO results: Not applicable/not performed for COPD. - Radiology results: Chest X-ray showed hyperinflation and flattened diaphragms, consistent with COPD. No acute infiltrates. - Blood test results: Full blood count within normal limits, CRP slightly elevated at 15 mg/L. - Skin prick test results: Not performed. - Any other relevant investigations: ECG showed normal sinus rhythm, no signs of right heart strain. Systemic Enquiry: - Skin issues: No active skin issues reported. - Mental health issues: Reports occasional low mood, denies formal diagnosis of depression or anxiety. - Bladder issues: No urinary incontinence or dysuria. - Gut issues: Occasional indigestion, managed with over-the-counter antacids. Plan: - Commence a 5-day course of oral prednisolone 30mg daily. - Prescribe a course of antibiotics (Amoxicillin 500mg TDS for 7 days) given increased sputum production and CRP elevation. - Review inhaler technique and adherence. - Refer to pulmonary rehabilitation programme. - Schedule follow-up appointment in 2 weeks to assess response to treatment and review long-term management plan. - Advise on smoking cessation resources (even though quit, reinforce benefits and offer support). - Encourage regular, light exercise as tolerated.

Presenting Complaint: - [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Complaint: - [describe history of presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current Problems: - [describe current problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [number of hospital admissions in the past 12 months] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [number of exacerbations in the past 12 months requiring steroids] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical History: [mention medical conditions, diagnoses, and relevant home medical equipment or supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Drug History: - [mention medications and non-prescription supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: - [mention smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention presence of damp or mould at home] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention occupation history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention exercise levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention presence of pets] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Number of Courses of Steroids in the Last Year (if asthma or COPD): - [mention number of courses of steroids in the last year] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary of Investigations: - [summarise lung function or spirometry results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [summarise FeNO results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [summarise radiology results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [summarise blood test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [summarise skin prick test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [summarise any other relevant investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Systemic Enquiry: - [mention skin issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention mental health issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention bladder issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention gut issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - [mention all actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)

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