DVUPCC patient handout

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Summary of Visit:
(Briefly explain the diagnosis in simple, patient-friendly language, and explain what it is to the patient. Use medical terminology for diagnosis, and explain it) Do not list subjective or objective information unless relevant. Use full sentences only. If I say that a patient 'likely' has a diagnosis, include this)

Treatment:
(Hyphenated list, only include new medications started today, do not include reference to medications patient is already on) (include other treatments reference that are not medications eg. nasal saline irrigation, rest)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin one 500mg tablet by mouth twice a day]
(do not include abbreviations eg. BID)
(if no treatment indicated, do not include this section)

Follow-Up Instructions: (include this header if instructions mentioned)
(Hyphenated list)
- [e.g., Repeat blood work in 3 days at your local lab] 
(if blood work is being ordered, include "blood work can be done at Island Health labs or LifeLabs. Nearest location to the clinic is a LifeLabs at 1120 Yates St, 2nd floor, open 7am-5pm weekdays. You can book an appointment online or walk-in. Most lab results can be viewed online at BC Health Gateway.")
(if xray is being ordered, include "x-ray can be done at Royal Jubilee Hospital or Victoria General Hospital, or West Coast Medical Imaging. Nearest location to the clinic is WCMI at 1120 Yates St, 2nd floor, open 8:30am-4:30pm weekdays, no appointment needed.")
(if CT, MRI, or ultrasound is being ordered, make reference that patient will receive a call to book this, and wait time is variable depending on urgency)
(if referral has been made to specialist, make reference that patient will receive a call to book this, and wait time is variable depending on urgency)
- [e.g., Attend your specialist appointment on DD/MMM/YYYY]
(if I indicate that patient will book a follow-up with me or will be called after results are in, include this)
(if no follow up has been booked or indication that I will call patient with results, include this statement: "If you have non-emergency concerns about the issue discussed today within the next month, call the clinic back in afternoon or evening and ask to leave a message for me. After one month, and for any other issue not discussed today, you will need to seek medical care by calling in the morning for a same day appointment, calling 811, or trying to access another provider.)

Go to ER or call 911 if:
(Hyphenated list of life threatening conditions relevant to their diagnosis)

If you do not have a primary care provider, make sure to register for the waiting list online at BC Health Connect Registry.

#User Instructions
(do not include medical abbreviations in this note eg. SOB, CP, BID)