Senior Template by Colin W | Dilato

Please see (level of training) (trainee’s name)‘s excellent note for complete details.

In brief, (patient’s name) is a (age)-year-old (gender) from (home, LTC, etc.) (alone, with family, etc.) referred for (RFR). Their PMH includes (relevant to RFR or severe/life-limiting illnesses). They present to hospital with (1-3 sentences about why they are coming to hospital now).

On exam, (relevant vital signs - anything abnormal or reassuringly normal) and (pertinent positives/negatives). Blood work is notable for (relevant/abnormal). ECG shows (findings). Imaging shows (summarize key findings - ie CT brain shows nil acute, CXR shows pulmonary edema, CT PE shows b/l segmental PE).

We will (admit to team X/discharge home/involve other service) with plan as follows: 1. First issue - leading diagnosis +/- key ddx, important/discharge-limiting investigations, general management 2. … 3. Best practices - discharge planning (ie does allied health need to be involved), code status, special dietary or DVTp considerations (ie dysphagia diet given possible aspiration, hold DVTp given plts