1
Header
- Date/time
- Clerking doctor + grade
- Source of history
2
Presenting Complaint
- Single sentence
3
HPI
- Chronological story
- Pertinent positives & negatives
4
PMH / DH / FH / SH
- Allergies in CAPS
- Independence / mobility
5
Examination
- NEWS2 score
- ABCDE findings
- Focused systemic exam
6
Investigations Performed
- ECG, bloods, ABG, imaging
7
Impression
- Primary diagnosis + differentials
8
Plan
- Investigations to send
- Treatment started
- Escalation status (DNACPR / ceiling)
- Senior review needed
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