Templates

Cannula Review D3 VIPS0 Flushes well Plan Cannula to remain in-situ, continue using --- VIPS (Visual Infusion Phlebitis Score) 0 No phlebitis → Observe cannula 1 Slight pain OR slight erythema → Observe cannula 2 Two of pain/erythema/swelling → Resite 3 All of pain/erythema/swelling → Resite ± treat 4 Extensive 3/palpable venous cord/pyrexia) → Resite ± treat 5 All & extensive 4 → Resite + treat Name (JMO) #123

Eyes (CN2-4,6) PEARL Peripheral vision intact Accommodation reflex intact Eye ROM normal, nil diplopia/nystagmus/saccades Face (CN5,7) Sensation intact V1-3, L=R Muscles of facial expression 5/5 L=R Jaw depression 5/5 Ears (CN8) Gross hearing intact Throat (CN9-10,12) Nil uvula/tongue deviation Tongue power 5/5 Nil vocal hoarseness Neck (CN11) Shoulder elevation 5/5 Neck lateral rotation 5/5 L=R

CURB-65 0/1 Confusion 0/1 Urea > 7 0/1 RR ≥ 30 0/1 BP (S < 90, D ≤ 60) 0/1 ≥65yo 0-1 1.5% mortality Outpatient 2 9.2% mortality Inpatient 3 22% mortality Inpatient ± ICU (if 4-5)

Death Certification Assessment Identity confirmed from wrist band Patient in bed, no signs of life No respiratory effort noted No response to verbal stimuli No response to central painful stimuli No carotid pulse palpable Pupils fixed and dilated bilaterally No heart sounds heard during 5 minutes of auscultation No breath sounds heard during 5 minutes of auscultation Death confirmed at TIME on DATE Plan Cremation Risk Advice completed Coronial Checklist: home team to kindly complete (ideally do this too if time permitting) Medical Certificate of Cause of Death: home team to kindly complete (do if home team documented expected cause of death or advised by consultant when notifying) Consultant notified/to be notified in the morning Family notified May they rest in peace Name (JMO) #

Admission date: Discharge date: AMO: Dr Specialty Specialist (Specialty) Discharge destination: Home Principal diagnosis: Headache --------------------------------------------------------------------------------------------------------------------------------------- Summary of Admission NAME is a AGE-year-old GENDER who presented to St George Hospital with Issues during Admission # --------------------------------------------------------------------------------------------------------------------------------------- Discharge Plan 1. Discharge to home 2. Medications - NEW - CHANGED - CEASED - Please continue taking your regular medications as previously prescribed 3. Please follow-up with your GP in 3-5 days - GP to kindly: - Prescribe medications and review changes as detailed - Provide referral 4. Follow-up with Dr X at PLACE on DATE (or approximation) - You will be contacted by the hospital (likely a private number) with appointment details. Please contact (02) XXXX XXXX if you have not heard from the hospital in 4 weeks. 5. If you have new or worsening symptoms or concerns, please see your GP or present to the nearest Emergency Department. --------------------------------------------------------------------------------------------------------------------------------------- Past Medical History Social History --------------------------------------------------------------------------------------------------------------------------------------- Thank you and kind regards, Dr YOUR NAME TEAM Intern On behalf of Dr AMO NAME (Specialist) St George Hospital (02) 9113 1111, pager #

ED Presentation [ Age ], [ Gender ], [ 3019_reason_for_visit ] [ Discharge -All Triage Information ] HPC PMHx [ MH_Past_Medical_Hx_ST ] Meds [ * Medication List ] Allergies [ Allergies ] FHx PSHx OE [ 3019_vital_signs_ab_flag ] Investigations Differentials Impression Plan - d/w Dr (EDSS) Name (JMO)

GCS (EVM) Eye opening response: spontaneously (4), to speech (3), to pain (2), nil (1) Verbal response: TPP oriented (5), answers Qs (4), inappropriate words (3), incomprehensible sounds (2), nil (1) Motor response: obeys commands (6), localises pain (5), flex to withdraw from pain (4), decorticate (3), decerebrate (2), nil (1)

HSDNM Chest clear ASNT CSNT No peripheral oedema

Sensation: intact UL + LL L=R Tone: intact UL + LL L=R, no clonus Power R L UL - Shoulder abduction C5-6 5 5 - Shoulder adduction C6-8 5 5 - Elbow flexion C5-6 5 5 - Elbow extension C7-8 5 5 - Wrist flexion C6-7 5 5 - Wrist extension C7-8 5 5 - Finger flexion C7-8 5 5 - Finger extension C7-8 5 5 - Finger abduction C8-T1 5 5 - Finger adduction C8-T1 5 5 LL - Hip flexion L1-3 5 5 - Hip extension L4-5 5 5 - Hip abduction L2-4 5 5 - Hip adduction L4-S2 5 5 - Knee flexion L5-S2 5 5 - Knee extension L3-4 5 5 - Ankle dorsiflexion L4-5 5 5 - Ankle plantarflexion S1-2 5 5 Reflexes R L UL - Biceps C5-6 + + - Triceps C7-8 + + - Brachioradialis C5-6 + + LL - Knee L3-4 + + - Ankle S1-2 + + - Babinski (↑/↓) L5-S1 ↓ ↓ Cerebellar Pronator drift NAD bilaterally Dysdiadochokinesia NAD bilaterally Dysmetria NAD bilaterally Heel-shin NAD bilaterally Foot tapping NAD bilaterally Gait - Walking Normal - Tandem Normal - Heels Normal - Toes Normal

PERC - if one false, do D-dimer <50yo HR < 100 SpO2 ≥ 95% No haemoptysis No unilateral leg swelling No oestrogen use No previous DVT/PE No surgery/trauma requiring hospitalisation <4w

Pre-Admission Clinic [ Age ] [ Gender ] [ 3019_reason_for_visit ] Planned Operation OPERATION for PROBLEM under Dr CONSULTANT on PLANNED DATE HPC Brief summary for future reference, they've already been worked up in outpatients PMHx [ MH_Past_Medical_Hx_ST ] Meds [ * Medication List ] Allergies [ Allergies ] PSHx OE Investigations Scans: what, where, when, do they need a more recent scan? Plan Please bring with you any scans, letters or health records to hospital Medications and fasting as per anaesthetics Call the hospital if you develop flu/COVID-like symptoms Name (JMO) #

Primary Survey A: own, patent B: RR X, SpO2 X%, speaking in full sentences, trachea midline, chest clear C: HR X, BP X, warm peripherally, radial pulse regular, HSDNM, PIVC in situ D: GCS 15, PEARL, moving all four limbs with good power, BSL X E: afebrile, no obvious injuries

Name (JMO) [ Age ], [ Gender ], [ 3019_reason_for_visit ] ATSP/Clinical review/Rapid Response/Code Blue for Progress What is happening now Issues # Issues during the admission PMHx O/E [ 3019_vital_signs_ab_flag ] Investigations Impression Plan - d/w Dr (MOIC) Name (JMO) #

Secondary survey No C-spine tenderness Able to rotate head L + R CN intact HSDNM Chest clear ASNT CSNT No peripheral oedema

SMART-COP 0/2 SBP < 90 0/1 Multi-lobular involvement on CXR 0/1 Albumin < 35 0/1 RR ≥ 25 (30 if >50yo) 0/1 HR ≥ 125 0/1 Confusion (new onset) 0/2 PaO2 < 70 (60 if >50yo) | SaO2 < 94% (91%) OR PaO2/FiO2 < 333 (250) 0/2 pH < 7.35 Risk of intensive respiratory/vasopressor support 0-2 Low 3-4 Moderate (18) 5-6 High (1/3) → consider ICU admission 7+ Very high (2/3) → consider ICU admission

(Reg) / (JMO) / Casey (CNC) - if Erin Casey is there! Stroke Call Time of stroke call: Time of arrival to ED: Last seen well: NIHSS: Time to scanner: Time to thrombolysis: History of Presenting Complaint Past Medical History [ Medication History (eMeds) ] Medications [ * Medication List ] Allergies [ Allergies ] Social History Examination [ 3019_vital_signs_ab_flag ] NIHSS: 1a. 1b. 1c. 2. 3. 4. 5a. 5b. 6a. 6b. 7. 8. 9. 10. 11. 1a. Consciousness [0] alert [1] arouses to minor stimulation [2] repeated stimulation to arouse OR movement to pain [3] postures/unresponsive 1b. Month & Age [0] both right [1] one right or dysarthric/intubated/trauma/language barrier [2] none right/aphasia 1c. Blink eyes & Squeeze hands [0] both right [1] one right [2] none right 2. Horizontal eye movements [0] normal [1] partial gaze palsy that can be overcome/corrects with oculocephalic reflex [2] forced gaze palsy that cannot be overcome 3. Visual fields [0] normal [1] partial hemianopia [2] complete hemianopia [3] bilateral hemianopia/blindness 4. Facial palsy (grimace if obtunded) [0] normal [1] minor (flat nasolabial, partial smile asymmetry) [2] partial paralysis of lower face [3] complete paralysis 5a. L UL drift 5b. R UL drift 6a. L LL drift 6b. R LL drift [0] nil (or amputation/joint fusion) [1] drift, doesn't hit bed [2] drift, hits bed OR some effort against gravity [3] no effort against gravity [4] no movement 7. Limb ataxia (finger-nose, heel-shin) [0] no ataxia OR doesn't understand/paralysed/amputation/joint fusion [1] in one limb [2] in two limbs 8. Sensation [0] normal [1] less sharp but can sense being touched [2] cannot sense/no response/coma 9. Dysphasia (describe a picture, name items, read sentences) [0] normal [1] mild-mod (obvious change without significant limitation) [2] severe (fragmented, inference needed, cannot identify items) [3] mute/no comprehension/gibberish/coma 10. Dysarthria [0] normal/intubated/unable to test [1] slurring but understood [2] unintelligble slurring or out of proportion to dysphasia/mute 11. Inattention/extinction [0] normal [1] one of visual/tactile/auditory/spatial/personal inattention or bilateral inattention [2] profound hemi-inattention (e.g. doesn't recognise own hand) or 1+ modality involved Investigations Impression Plan Name (JMO) #

# Stroke workup - BP: - HbA1c (aim <7%): - LDL-C (aim <1.8): - Total cholesterol (aim <4): - Telemetry: - TTE: - CTA:

Nil fever / chills / rigors / sweats / anorexia / weight loss / fatigue Nil headache / dizziness / change in vision/hearing/taste/smell Nil weakness / paraesthesias / numbness Nil photophobia / phonophobia / neck pain / neck stiffness Nil rhinorrhoea / anosmia / sore throat / post-nasal drip / sinus pain / otalgia Nil chest pain / SOB / palpitations / syncope / cough Nil abdo pain / nausea / vomiting / constipation / diarrhoea / blood in stools / mucus in stools Nil dysuria / urinary frequency / urinary urgency

[ 3019_vital_signs_ab_flag ]

(AT #) / (JMO #) TEAMNAME Ward Round [ Age ] [ Gender ] [ Diagnosis ] Progress OE Obs stable, afebrile Investigations Plan Name (JMO) #

Warfarin Charting Target INR: 2-3 (bileaflet or tilting-disk mitral mechanical valve 2.5-3.5) Brand: Coumadin (default)/Marevan INR Warfarin dose D0 D-1 D-2 D-3 D-4 D-5 Plan Warfarin for today charted as Xmg Repeat INR tomorrow Name (JMO) #

Well's Score for DVT: /9 <4 D dimer, ≥4 CTPA 0/1 Active cancer (treatment/palliation <6mo) 0/1 Bedridden >3d OR major surgery <12w 0/1 Calf swelling >3cm compared to other leg (10cm below tibial tuberosity) 0/1 Collateral (nonvaricose) superficial veins present 0/1 Entire leg swollen 0/1 Localised tenderness along deep venous system 0/1 Pitting oedema confined to symptomatic leg 0/1 LL paralysis/paresis/recent plaster 0/1 Previous DVT 0/-2 Alternative diagnosis as/more likely

Well's Score for PE: /11 [<2 PERC, 2-6 D-dimer, >6 CTPA] 0/3 Clinical signs/symptoms of DVT 0/3 PE is as/most likely diagnosis 0/1.5 HR > 100 0/1.5 Previous DVT/PE 0/1 Haemoptysis 0/1 Cancer treatment/palliation <6mo

Celecoxib (Celebrex) up to 200mg twice daily (12h apart)

Ibuprofen (e.g. Neurofen) up to 2 tabs (400mg) three times a day (~8h apart)

Metoclopramide (e.g. Maxalon) up to 10mg three times a day

Panadeine forte (paracetamol 500mg + codeine 30mg) up to 2 tabs four times a day (4-6 hours apart)

Paracetamol (e.g. Panadol) up to 2 tabs (1000mg) four times a day (4-6h apart)

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FBC UEC CMP LFT CRP Coags APTT INR PT D dimer Troponin TFT BSL HbA1c Lipid profile Group & hold Crossmatch (Add-on) Blood cultures Urine MCS Wound swab MCS COVID-19/Flu Rapid PCR COVID-19/Flu/RSV PCR CXR CT Brain Paracetamol 1000mg qid PRN for pain/fever Ibuprofen 400mg tds PRN for pain/fever Endone 5mg QID PRN for pain Ondansetron 4-8mg multiple route tds PRN for nausea Metoclopramide 5-10mg multiple route tds PRN for nausea Loratadine 10mg daily PRN for itch Coloxyl & Senna 2 tabs bd Movicol 2 sachets bd Consult physiotherapy request Consult occupational therapy request Consult speech pathology request Consult social work request Consult MO request (for after hours jobs)

FBC UEC LFT CRP D-dimer LDH Ferritin

Junior Medical Officer St George Public Hospital M: | E: @health.nsw.gov.au Visit the NSW Health website for the latest information on COVID-19. Good planets are hard to find - please think of the environment before printing this email.

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