What is happening at the current time?
Briefly describe the current situation.
Include patient name (if applicable) and relevant details (e.g., location, date/time).
What is the clinical background or context?
Summarize the patient’s medical history, diagnosis, and relevant treatments.
Include any previous assessments or changes in condition.
What do you think the problem is?
Provide your assessment of the situation based on observations and clinical data.
Include vital signs, lab results, or any pertinent information that supports your assessment.
What do you suggest we do to resolve the issue?
Clearly outline your recommendations for the next steps.
Specify any actions you believe should be taken and any necessary follow-up.
Ensure clarity and conciseness in each section.
Use bullet points for easy reading where appropriate.
Include contact information if needed for follow-up or questions.
Templates
Templates