Consultant: [Name of Consultant]
Department: [e.g., Acute Medicine / General Surgery]
Patient Name: [Full Name]
DOB / Hospital Number: [Details]
Admission Date: [DD/MM/YYYY]
Discharge Date: [DD/MM/YYYY]
Method of Admission: [e.g., Via ED / Elective]
Primary Diagnosis: [The definitive cause for admission—avoid jargon like ‘urosepsis’, or ‘collapse ?cause’ or ‘social admission’]
Secondary Diagnoses: [Any other conditions treated during the stay]
Relevant Past Medical History: [Key chronic conditions only]
Aim for 3–4 concise sentences per paragraph. Focus on the “story” of the admission.
Presentation: [Brief summary of symptoms and initial findings]
Investigations: [Significant positive results only (e.g., “CT Head showed…”)]
Management: [Treatments provided, operations performed, or specialist reviews]
Complications: [Include any iatrogenic issues or significant setbacks, if any]
Known Allergies: [List allergy and reaction type]
New Medications Started: [Drug Name, Dose, Frequency, Duration, and Indication]
Medications Stopped/Changed: [State which drug and the clinical reason why]
Regular Medications Continued: [Confirm if pre-admission meds are unchanged]
Tests Awaiting Results: [List specific tests]
Responsibility for Results: [e.g. “Medical Team 1 will review the biopsy results on [Date]”]
Note: Please do not ask the GP to chase hospital-ordered investigations.
Action for GP: * [e.g., “Please repeat U&Es in 7 days to monitor ACE-inhibitor.”]
[e.g., or “Please monitor BP weekly for 1 month.”]
Action for Patient/Family: * [e.g., “Complete the 5-day course of Amoxicillin.”]
[e.g., or “Seek medical advice if you develop redness or swelling at the wound site.”]
Note. Be specific and reasonable, and only ask GP to do things that you cannot do easily.
Hospital Follow-Up: [Clinic Name, Timeframe, and Location—ensure this is already booked/requested by your team]
Community Services: [e.g., District Nurse booked for daily dressings starting tomorrow]
Name: [Your Name]
Rank/Grade: [e.g., FY1 / SHO]
Bleep/Contact Number: [Number]
Date: [Current Date]
To help you see how the theory translates into practice, here is a mock scenario for a common presentation: a patient admitted with a community-acquired pneumonia and a secondary finding of atrial fibrillation.
Consultant: Prof. J. Smith
Department: Respiratory Medicine
Ward: Ward 4 (Acute Medical Unit)
Patient Name: Mr. Arthur Miller
DOB / Hospital Number: 12/05/1955 | NH123456
Admission Date: 15/02/2026
Discharge Date: 21/02/2026
Method of Admission: Emergency Department referral
Primary Diagnosis: Left Lower Lobe Community-Acquired Pneumonia (CURB-65 score: 2).
Secondary Diagnoses: New-onset Atrial Fibrillation (Rate-controlled).
Relevant Past Medical History: Type 2 Diabetes, Hypertension, Osteoarthritis.
Mr. Miller presented with a three-day history of productive cough, pleuritic chest pain, and rigors. On admission, he was febrile (38.5°C) and hypoxic, requiring 2L of oxygen to maintain saturations.
Initial investigations included a chest X-ray, which confirmed consolidation in the left base. Bloods showed an elevated CRP (145) and White Cell Count (16). An ECG performed on admission incidentally showed Atrial Fibrillation with a ventricular rate of 115 bpm.
He was treated with a 5-day course of IV Co-amoxiclav, subsequently stepped down to oral antibiotics. His oxygen requirement resolved within 48 hours. Regarding his AF, he was started on Bisoprolol for rate control and apixaban for anticoagulation (CHA2DS2-VASc score: 3). He remained hemodynamically stable throughout his stay.
Known Allergies: Penicillin (REACTION: Anaphylaxis). Note: Patient was actually treated with Doxycycline, not Co-amoxiclav, due to this allergy.
New Medications Started: 1. Doxycycline 200mg OD (Oral) – 2 days remaining to complete 7-day course for pneumonia. 2. Bisoprolol 2.5mg OD (Oral) – For rate control of AF. 3. Apixaban 5mg BD (Oral) – For anticoagulation.
Medications Stopped/Changed: Ramipril held temporarily due to acute kidney injury (resolved); restarted on discharge.
Tests Awaiting Results: Sputum cultures.
Responsibility for Results: The Respiratory Team (Reg 1) will review these on 24/02/2026 and contact the GP only if a change in antibiotics is required.
Action for GP: * Please check U&Es and BP in 7 days to ensure renal function remains stable on restarted Ramipril.
Review heart rate in 2 weeks to ensure Bisoprolol 2.5mg is sufficient for rate control.
Action for Patient/Family: * Complete the final 2 days of Doxycycline.
Attend the follow-up chest X-ray in 6 weeks (appointment sent by post).
Hospital Follow-Up: Please repeat Chest X-ray in 6 weeks (as per BTS guidelines) to ensure resolution.
Community Services: No community input required at this time.
Name: Dr. Sarah Jenkins
Rank/Grade: FY1
Bleep/Contact Number: 4452
Date: 21/02/2026
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