Respiratory[autotexts]

Clinic letters & admin / Consultation template

New respiratory outpatient

The general clerking skeleton every other consultation template on this site is built on, with performance status and a smoking record that counts.

Fills in order
  1. 1History of presenting complaint
  2. 2Previous medical history
  3. 3Current medication and allergies
  4. 4Family history
  5. 5Smoking status
  6. 6pack-years
  7. 7E-cigarettes or vaping
  8. 8Recreational drug use
  9. 9Very brief advice given
  10. 10Referred to stop smoking service
  11. 11Nicotine replacement or pharmacotherapy…
  12. 12Alcohol
  13. 13Occupation, current and previous
  14. 14Home circumstances and who else is at ho…
  15. 15Pets and birds
  16. 16Recent travel

and 22 more, in the block below.

Paste block 38 fields 
History of presenting complaint:
[]

Previous medical history:
[]

Current medication and allergies:
[]

Family history:
[]

Personal and social history:

Smoking status: [current, ex or never] (pack-years [])
E-cigarettes or vaping: [device and duration, or no]
Recreational drug use: [drug, route, duration, or no]
Very brief advice given: [yes, no or not applicable]
Referred to stop smoking service: [yes, no or not applicable]
Nicotine replacement or pharmacotherapy offered: [type, or no]

Alcohol: []
Occupation, current and previous: []
Home circumstances and who else is at home: []
Pets and birds: []
Recent travel: []

On examination:

Height [] cm   Weight [] kg   BMI []
SpO2 []% on air   BP [] mmHg   Pulse [] bpm   Respiratory rate []

ECOG performance status []

There was no pallor, cyanosis, jaundice, oedema, clubbing or cervical
lymphadenopathy.

Heart sounds: []
Breath sounds: []
Abdomen: []

Radiology:
[]

Hand-held spirometry:
FEV1 [] L ([]% predicted)
FVC [] L ([]% predicted)
FEV1/FVC ratio []%
Peak flow [] L/min ([]% predicted)

Blood tests:
[]

Impression:
[]

Management plan:
[]

How to use it

Record the ECOG performance status in every letter where lung cancer is even a vague possibility. Patients get discussed at a regional lung cancer MDT on the strength of the letter alone, and surgeons and oncologists cannot plan treatment without it — a missing performance status sends the referral back and costs the patient a fortnight. Fill the smoking lines even when the answer is never: never is a finding in a breathless patient, and the fields for very brief advice and referral exist so that what you offered is in the record rather than in your memory. The birds, pets, travel and occupation lines are four seconds of dictation that occasionally rewrite the whole diagnosis.

Why it says that

None of this is in the copied text. It is here so you can check the block against its source, and change it when the source changes.

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