Respiratory Ward Round Note

Current Status and Overnight Events: [Summary of overnight events, current oxygen requirement, and general clinical trajectory including whether the patient is improving, stable, or deteriorating] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Active Problems: [Each active diagnosis, its current clinical status, and its specific problem-oriented plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each problem as a numbered item. Never invent or infer diagnosis. For each problem, include an indented status line summarising the current clinical state based on observations, investigations, and narrative, and an indented plan line using action-oriented language. Leave an empty line between each problem. Only include a NIV settings sub-line if NIV is explicitly mentioned in relation to that specific diagnosis, stating the IPAP, EPAP, backup rate, and leak status. Omit any sub-line that is not explicitly mentioned.) Past Medical History: [Relevant medical conditions, previous hospitalisations, surgeries, and chronic medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each condition on a new line.) Escalation Status: [Ceiling of care, DNACPR status, and ICU suitability or general escalation plan] (Only include if ceiling of care, DNACPR, or ICU suitability is explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each item on a new line, omitting any sub-item that is not explicitly mentioned.) History of Present Illness: [Detailed narrative of the current respiratory illness including onset, progression, associated symptoms, and relevant timeline] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Review of Systems: [Relevant symptoms across all systems as discussed, grouped by system where multiple systems are represented, prioritising respiratory symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences. Do not infer or include any symptoms not explicitly stated.) Medications: [Current medications including respiratory medications, bronchodilators, steroids, antibiotics, and any other relevant medications with names, doses, and frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each medication on a new line.) VTE Prophylaxis: [Current VTE prophylaxis including the agent used, dose, and frequency, or whether stockings are in use, or whether VTE prophylaxis is not indicated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) Allergies: [Known drug allergies and the nature of adverse reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Social History: [Smoking history, occupational exposures, and relevant environmental factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Observations: [Current clinical observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) NEWS: [current National Early Warning Score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) RR: [current respiratory rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) SpO2: [current oxygen saturation and oxygen delivery method and rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) HR: [current heart rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) BP: [current blood pressure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Temp: [current temperature in degrees Celsius] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Physical Examination: [General appearance and physical examination findings, excluding current vital signs which are documented in the Observations section] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) [Pulmonary examination findings including inspection, palpation, percussion, and auscultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) [Cardiovascular examination findings relevant to the patient's respiratory status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) NIV Settings and Weaning Plan: [Current status of NIV use, settings including IPAP, EPAP, backup rate, and leak status, and the plan to wean the patient from NIV] (Only include this section if a complex NIV plan is explicitly mentioned in the transcript, contextual notes or clinical note that cannot be adequately summarised under an active diagnosis, else omit section entirely. Write each item on a new line.) Diagnostic Studies: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Group results by modality and list chronologically for serial results. Omit any subsection not explicitly mentioned.) Bloods: [Relevant laboratory results including names of tests and their values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this subsection entirely. Write as a list.) ABG: [Arterial blood gas analysis results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this subsection entirely. Write as a list.) Imaging: [Chest imaging results including the modality and key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this subsection entirely. Write as a list.) Other: [Other diagnostic results including ECG findings, scoring tools, or pulmonary function tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this subsection entirely. Write as a list.) MDT Input: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each team member or specialty on a new line, omitting any sub-item not explicitly mentioned.) Physiotherapy: [Summary of physiotherapy input, assessment, or plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Nursing concerns: [Summary of specific nursing concerns or observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Social Work: [Summary of social work input or updates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) [Name of any other specialty providing input]: [Summary of input from that specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Clinical Impression: [Document the clinician's explicitly stated primary respiratory diagnosis and any differential diagnoses with the clinical reasoning provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in paragraphs of full sentences.) Discussion with Patient on Ward Round: [Summary of the discussion held with the patient during the ward round, including explanations provided, questions raised by the patient, and the patient's understanding of and agreement with the plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: [Therapeutic interventions, medication adjustments, and monitoring parameters discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each item on a new line.) Discharge Planning: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each item on a new line, omitting any sub-item not explicitly mentioned.) Estimated discharge timeframe: [Target date or timeframe for discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Barriers: [Factors hindering or delaying discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Required support: [Support, services, or patient education needed for safe discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit this line.) Follow-Up Plan: [Details of the follow-up plan including outpatient appointments and referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Jobs: [Tasks or actions to be completed by the clinical team following this ward round] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each task on a new line.)