PATIENT
John Smith
DATE OF DISCHARGE
1 November 2024
DISCHARGE/TRANSFER/HANDOVER
Discharged home
PROBLEM LIST
68-year-old male
* Severe peripheral artery disease, bilateral lower limbs, managed with endovascular revascularisation
* Type 2 Diabetes Mellitus, controlled with oral medication, continued monitoring
* Hypertension, controlled with medication, continued monitoring
INTERVENTIONS
* 25 October 2024: Right superficial femoral artery angioplasty and stenting
* 27 October 2024: Left popliteal artery angioplasty
POSTOPERATIVE COURSE
Stable postoperative course, no major complications. Minor wound ooze right groin, managed with dressing changes. Patient ambulating with aid. Pain well-controlled with oral analgesia. No signs of infection.
DISCHARGE NOTES
* Follow-up with vascular surgery clinic in 2 weeks
* Keep incision sites clean and dry, regular dressing changes as instructed
* Elevate lower limbs when resting
* Continue all usual medications
* Monitor for signs of infection: redness, swelling, increased pain, fever
* Attend to GP for wound check if concerns arise
* Specific measures at follow-up: assessment of wound healing, arterial duplex scan bilateral lower limbs
FOLLOW-UP DATE
2 weeks
DOCTORS TO BE COPIED IN
Dr Sarah Lee, GP
Dr Mark Jones, Endocrinologist
(All notes should be listed without full stops at the end of the sentence.)
(Use British English spelling to generate all notes.)
(No full stops to be used after titles or initials.)
(All numbers to be in numerical format, not text.)
(Generate notes in telegraphic style. Use short phrases, no filler words. Omit articles such as the, a, an. Summarised, concise format preferred.)
PATIENT
[Full name of patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
DATE OF DISCHARGE
[Date of discharge] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
DISCHARGE/TRANSFER/HANDOVER
[Whether the patient is being discharged, transferred to another facility, or handed over to another doctor] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
PROBLEM LIST
[Patient age]-year-old [male or female]
[List of all important underlying conditions including severity of each condition and treatment received during the hospital stay] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as a bulleted list.)
INTERVENTIONS
[List of all procedures performed including dates of each procedure as per the linked theatre transcripts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
POSTOPERATIVE COURSE
[Description of the patient's clinical course during the hospital stay including any postoperative events, complications, and the management thereof] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
DISCHARGE NOTES
[Advice given at the time of discharge including follow-up instructions, wound care, and any specific measures to be taken at the follow-up visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
FOLLOW-UP DATE
[Interval before follow-up or specific follow-up date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
DOCTORS TO BE COPIED IN
[Names of all doctors involved in the patient's care to whom the report should also be sent] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)