Clinician Specialty: Healthcare Assistant
Previous Admissions & Self-Management:
Patient's last hospital admission was approximately three months ago for a severe asthma exacerbation. The onset was sudden, following a viral infection.
Triggers that led to admission included a worsening cough, increased wheezing, and significant shortness of breath, which developed rapidly over 24 hours.
Patient attempted to contact their GP but was advised to call 111, who then recommended emergency services.
Patient assesses that they generally manage their asthma well day-to-day with regular medication, but struggles during periods of illness or high stress.
Patient is aware of warning signs for their condition, including increased cough, wheezing, and breathlessness, and knows to use their reliever inhaler.
Patient perceives their prescribed preventer and reliever inhalers as highly effective when used correctly.
Recent medication review by the GP occurred two months prior to this admission, with no changes made.
Last specialist (respiratory consultant) appointment was on 1 November 2023.
Patient would like additional help with stress management techniques to prevent asthma flare-ups and further education on identifying early signs of infection.
Medical History & Records Review:
Patient confirmed documented conditions of asthma and mild eczema. No additional conditions are currently being treated.
Medications & Allergies:
Known allergies include penicillin (rash) and house dust mites (rhinitis). No food or other substance allergies.
Patient reports good adherence to prescribed medications, using their preventer inhaler twice daily and reliever as needed.
No recent changes to medications reported.
Patient occasionally purchases over-the-counter antihistamines for seasonal allergies.
Inhaler Review:
Patient is using a Fostair Nexthaler (preventer) and Ventolin Evohaler (reliever).
Patient demonstrated good understanding of correct inhaler technique for both devices.
COPD Exacerbations:
Not applicable, patient has asthma, not COPD.
Lifestyle & Vaccinations:
Height (m): 1.65
Weight (kg): 78
BMI: 28.7
Weight management signposted: Yes, patient was signposted to local weight management services.
Smoking status: Never smoked.
Cessation advice given: Not applicable.
Cessation referral: Not applicable.
Stop smoking service signposted: Not applicable.
Alcohol units per week: Approximately 6 units per week.
Patient advised about alcohol: Yes, advised on recommended weekly limits.
Substance misuse / illicit drug use: Denies any substance misuse or illicit drug use.
Physical activity level: Engages in moderate intensity exercise (brisk walking) 3 times a week for 30 minutes.
Physical activity signposted: Yes, patient was signposted to local walking groups and online resources for physical activity.
Last influenza vaccination: 1 November 2023
Last pneumococcal vaccination: 1 November 2022
Last COVID-19 vaccination: 1 November 2023 (booster dose)
Shingles vaccination: Not yet indicated based on age.
RSV vaccination: Not yet indicated.
Immunisation status REQUIRED: Up-to-date with routine vaccinations, including flu and pneumonia. COVID booster received.
Immunisation advice given: Advised on upcoming seasonal flu vaccination and future COVID boosters.
NHS Health Check indicated: Yes, recommended due to age and BMI.
COPD Warning Signs Education:
Not applicable, patient has asthma, not COPD.
Heart Failure Warning Signs Education:
Not applicable, no history of heart failure.
Patient Care Plan Summary:
This discovery call focused on reviewing your asthma management and overall health. We discussed your last hospital admission for an asthma flare-up and noted good understanding of your condition's warning signs. You manage your asthma well day-to-day with your Fostair and Ventolin inhalers. We explored your lifestyle, including your excellent vaccination status, and provided information on healthy eating and increasing physical activity. You expressed interest in learning stress management techniques and understanding early infection signs.
Primary Health Goals:
* Improve stress management to reduce asthma triggers.
* Increase understanding of early infection warning signs relevant to asthma.
* Engage with recommended weight management resources.
* Attend NHS Health Check.
**Previous Admissions & Self-Management**
[Description of patient's last hospital admission including whether onset was sudden or gradual] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Details of triggers that led to admission such as infection, breathing changes, or symptom progression in preceding days] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Information about whether patient sought help from GP or 111 before admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient's assessment of how well they manage their long-term condition day to day] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient's knowledge of warning signs for their condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient's perception of medication effectiveness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Information about recent medication reviews by GP or pharmacist] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Date of last specialist appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Areas where patient would like additional help with their condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Medical History & Records Review**
[Patient confirmation of documented conditions and any additional conditions being treated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Medications & Allergies**
[Known allergies to medications, foods, or other substances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient adherence to prescribed medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Recent changes to medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Medications prescribed privately or purchased over the counter] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Inhaler Review**
[Types of inhalers patient is using] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
[Patient understanding of correct inhaler technique] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**COPD Exacerbations**
[Number of times in past year patient needed steroids or antibiotics for worsening breathing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
**Lifestyle & Vaccinations**
**Height (m)**: [patient height in meters] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Weight (kg)**: [patient weight in kilograms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**BMI**: [calculated body mass index] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Weight management signposted**: [whether weight management resources were provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Smoking status**: [current smoking status and history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Cessation advice given**: [whether smoking cessation advice was provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Cessation referral**: [whether referral to cessation services was made] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Stop smoking service signposted**: [whether stop smoking services were highlighted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Alcohol units per week**: [estimated weekly alcohol consumption in units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Patient advised about alcohol**: [whether alcohol advice was given] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Substance misuse / illicit drug use**: [information about substance use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Physical activity level**: [patient's current activity and exercise habits] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Physical activity signposted**: [whether physical activity resources were provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Last influenza vaccination**: [date of last flu vaccination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Last pneumococcal vaccination**: [date of last pneumonia vaccination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Last COVID-19 vaccination**: [date of last COVID booster] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Shingles vaccination**: [shingles vaccination status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**RSV vaccination**: [RSV vaccination status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Immunisation status REQUIRED**: [overall vaccination status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**Immunisation advice given**: [whether vaccination advice was provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**NHS Health Check indicated**: [whether NHS Health Check was recommended] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
**COPD Warning Signs Education**
[Documentation that COPD warning signs were explained including increased breathlessness, sputum changes, cough, fever, or prolonged mild illness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
**Heart Failure Warning Signs Education**
[Documentation that heart failure warning signs were explained including shortness of breath, swelling, weight gain, fatigue, or reduced appetite, and instruction to contact via Doccla app] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely.)
**Patient Care Plan Summary**
[Patient-friendly summary of key findings and management plan for inclusion in patient's care plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in clear, accessible language.)
**Primary Health Goals**
[Specific health goals identified and agreed upon with patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.)
