Y3 Medical Documentation - Completed Example by Dr Matthew Mathieson (School of Medicine and Dentistry)

Initial Information:

nommathieson3 — 2025-08-31 16:26:27 UTC

Patient: Mrs Ellen
ID number: 123456
Ward: ABC
06/09/22 12:00
Ward round: Dr Sherif (Medical Consultant)

Presenting Complaint and Past Medical History:

nommathieson3 — 2025-08-31 16:28:56 UTC

28F admitted with SOB. Referred to Medicine for ?PE due to positive D-dimer. She has had x1 treatment dose of clexane
PMH: Previous DVT (inc year), previous investigations for asthma

Note: if this is clerking information you may require further information here, eg drug history, dosages of medications give, etc

Investigations:

nommathieson3 — 2025-08-31 16:30:27 UTC

Inv:
- D-Dimer - positive (inc. actual value)
- Troponin - negative
- CXR, ECG, other bloods in past 24 hours, etc
- Any other investigations reviewed by senior clinician at time of ward round

Ward Round Information:

nommathieson3 — 2025-08-31 16:35:00 UTC

Today:
- Still feeling short of breath, denies chest pain.
- She is concerned about a clot in her lungs.
- CTPA discussed with her (make a note of verbal/written consent for any investigation/procedure that the patient consents for)
O/E:
- NEWS = 4. 99% RA. HR 115, RR 22
- Alert. Looks well. Speaking in full sentences
- Bilateral wheeze. No focal signs. Calves SNT

Note: if other examinations are performed, document them too. If you are usure about an examination finding, ask the person examining.

Impression, Plan, and Sign Off:

nommathieson3 — 2025-08-31 16:36:34 UTC

Imp: Need to exclude PE
Plan:

Salbutamol nebs
Peak flow pre/post nebs
CTPA this morning (needs new cannula)
If CTPA +ve may need anticoagulation – discuss with haematology
Confirm above plan with supervising clinician

Note: Impression can be a bit more explanatory/longer if required - remember, it's a way of explaining your thinking and justifying your plans/actions

nommathieson3 — 2025-09-01 07:50:43 UTC

Example ECG:

nommathieson3 — 2025-09-01 07:53:23 UTC

Note: you can reference investigations that you have reviewed on the ward round by stating which investigation it was, what time and date it was completed, and who it was reviewed by

Example Chest X-Ray:

nommathieson3 — 2025-09-01 07:53:50 UTC

Note: you can reference investigations that you have reviewed on the ward round by stating which investigation it was, what time and date it was completed, and who it was reviewed by

nommathieson3 — 2025-09-01 08:19:38 UTC

Signed by Medical Student

nommathieson3 — 2025-09-01 08:20:13 UTC

Countersigned by supervising Medical Doctor with grade, GMC number, and bleep/contact number