IRH IDL (QIP)

(Ensure all sections are internally consistent. For example, if a medication change is mentioned in the Brief Summary of Admission, it must also be listed in the Medication Changes and Reason section. The entire document should be cross-referenced for consistency.) Presenting Complaint: [Patient's presenting symptom or chief complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Summarise in 7 words or less. Write as a symptom, never a diagnosis.) Past Medical History: [Relevant past medical history including chronic conditions and major diagnoses prior to the current admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list separated by commas.) Brief Summary of Admission: [Key clinical decisions, interventions and newly confirmed diagnoses made during the admission, including the rationale for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Focus only on what was done and why. Do not include history of presenting complaint or physical examination findings. Write as a bullet point list.) Investigations: [Completed investigations and their relevant results that informed clinical decision making during the admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Include only objective tests such as blood tests, ECGs and imaging studies with their results. Do not include physical examination findings. Do not include normal results unless directly relevant to the admission. Do not include pending or planned investigations. Write as a bullet point list with the investigation name followed by its result.) Medication Changes and Reason: [All medications started, stopped or changed during the admission and the explicitly stated reason for each change] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Ensure this list is comprehensive and includes all medication changes mentioned anywhere in the document. Write as a bullet point list.) GP to Follow Up: [Key follow-up actions requested of the GP] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a bullet point list.)