Assessment			Plan
Obs	Results	Diagn	Ix	Tx	Review
•ABCDE •NEWS •I/Output •Glucose •Stool	•ABG •ECG •Urine •Pathol. •Radiol.	•Diagnosis ± Scores •Problems	-Awaited -New •Referrals	•Fluids •Oxygen •Drugs* •VTE •Bundles	•Reassess •Escalation •Destination •EDD+TTO •QI

Comments

• Obs=Observations
• ABCDE: if acutely unwell
• Results: 1) bedside, 2) online
• Diagn(osis): document working diagnoses
• Severity scores (CURB65, ABCD2, etc)
• Problems= Problem list, comorbidities
• Ix=Investigations:
• - awaited: check requested/accepted
• - new: request/hand over
• Referrals: to other specialties
• Tx=Treatments
• Drugs*: Antibiotics need indication + duration
• Monitor: Jobs; criteria-led discharge
• Escalation: suitability for ICU/CPR
• EDD=Expected Day of Discharge
• TTO=Discharge letter + medication
• QI=Quality improvement: feedback, lesson learnt, etc.

Plain Text

|______Assessment____|_________Plan__________|
|_Obs_|_Res__|_Diagn_|__Ix__|__Tx___|_Review_|
|ABCDE|ABG   |Diagn. |Awtd  |Fluids |Reassess|
|NEWS |ECG   |±Scores|New   |Oxygen |Escal.  |
|I/O  |Urine |Probl. |Refrls|Drugs* |Destin. |
|Gluc |Pathol|       |      |VTE    |EDD+TTO |
|Stool|Radiol|_______|______|Bundles|QI______|
        

Minimalist

_____Assessment____|_____Plan_________
_Obs|__Res_|_Diagn_|__Ix_|__Tx__|_Rvw_
A2E |ABG   |Diagn. |Awtd |Fluids|Time 
NEWS|ECG   |±Scores|New  |O2    |Escal
I/O |Urine |Probl. |Refer|Drugs*|Dest.
Gluc|Pathol|       |     |VTE   |EDD  
____|Radiol|_______|_____|Bndl__|QI___