Specialised Nurse Template
Multiple Sclerosis Newly Diagnosed Assessment
A professional Specialised Nurse template for healthcare professionals.
About this template
Need a clear and concise way to document your patient's journey with Multiple Sclerosis? This Multiple Sclerosis Newly Diagnosed Assessment template is perfect for specialised nurses and other healthcare professionals. It helps you capture essential information, from diagnosis and treatment to symptoms and lifestyle considerations. This template ensures comprehensive documentation, covering key areas like disease-modifying therapies, education, and patient support. Streamline your note-taking process and improve patient care with this essential tool. This template is designed to be used with Heidi, the AI medical scribe, to make documentation even easier.
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Presenting History:
Diagnosis:
Diagnosed in 2023, presenting with visual disturbances and mobility issues. Diagnosed by Dr. Smith at City Hospital. MRI and VEPs were performed.
Type of MS: Relapsing Remitting MS
Disease Modifying Therapy:
Currently on Ocrevus, started in 2023. No current side effects. Last MRI performed in June 2024, next due in December 2024.
Discussed mode of action, method of delivery, side effects, efficacy, monitoring requirements.
Education/Discussions:
* What is MS
* Types of MS
* Disease modifying therapies
* How to live well with MS
* Diet
* Exercise
Literature provided:
Newly Diagnosed Booklet, DMT Booklet, MS Register Card
MS Related symptoms:
Mood:
Patient reports low mood, impacting daily activities. Discussed coping strategies and referred to a therapist.
Memory/Cognition:
Patient reports some memory difficulties. Referred to neuropsychology for assessment.
Vision:
Patient reports blurred vision. Advised to see an ophthalmologist.
Lower limbs/Mobility:
Patient reports mobility issues. Advised to attend physiotherapy.
Bladder:
Patient reports bladder urgency. Advised to see a continence nurse.
Fatigue:
Patient reports fatigue. Advised to attend fatigue management course.
Social Situation:
Patient is currently employed but concerned about future work prospects. Discussed benefits and support network.
Co-morbidities:
Patient has hypertension, managed with medication.
Management Plan:
* Referral to therapist.
* Referral to neuropsychology.
* Referral to ophthalmologist.
* Referral to physiotherapist.
* Referral to continence nurse.
* Referral to fatigue management course.
* Review in 3 months.
Date: 1 November 2024
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