DRAFT v5 – COVID-19 assessment


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DRAFT v5 – COVID-19 assessment
Edit the text below <p>Please edit the text in the box to reflect your clinical history and examination. <br><span style="color: yellow;"><b>NOTE: Use Shift + Enter to create a new line for correct line spacing.</b></span></p> <p>The templates (links on the right) can be used to help produce comprehensive documentation. The text will revert back to default on a page refresh.</p> Use the buttons to add/remove sections and Shift+Enter for new lines
History [ ← HPC template || <p style="color:red;"><b>Edit text below and copy and paste into template or directly into clinical notes</b> <div id="quicknote-wrapper" contenteditable="true"> &#8211; Spoken to <span class="edit-text">patient</span> &#8211; Confirmed 3 identifiers &#8211; Presently at <span class="edit-text">home</span> <br>&#8211; Given consent to access notes <br>&#8211; Has <span class="edit-text">not</span> had a COVID test &#8211; Has had <span class="edit-text">no</span> COVID contacts </div> || ]

– First day of symptoms:
Pertinent negatives [ Symptom based – pertinent negatives template ]
– No fever or chills – No cough – No haemoptysis – No loss of sense of smell or taste
– No breathlessness – No fatigue
– No chest pain – No collapse – No headache – No neck stiffness, photophobia or rash
– No focal neurological symptoms
– No nasal congestion – No sore throat – No myalgia – No appetite loss – No nausea or vomiting – No diarrhoea – No urinary symptoms
– Not drowsy/confused – extremities are warm and well perfused – skin is normal colour – normal urine output
Further history [ ← Use Assessment & Mx template for risk groups ]
– No high risk (clinically extremely vulnerable) conditions
– No moderate risk (clinically vulnerable) conditions
Examination [ ← || || Remote template || F2F template]
Assessment [ ← Assessment & Mx template | Consider the Differential Diagnosis → ]
– Impression: Likely COVID-19 – Mild symptoms + Low risk signs
Management [ ← Assessment & Mx template ]
– Explanation, advice and discussion – shared management plan agreed upon
– Sign-posted to NHS self management, isolation and safety netting information – https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/
– Please arrange a COVID-19 test before the 8th day of illness – https://www.nhs.uk/ask-for-a-coronavirus-test
– Self isolate for 10 days (household for 10 days) or until your test is confirmed negative
– Stay at home, rest (not advisable to push yourself), and drink 6-8 glasses of water a day
– Antipyretics as needed (seek advice if fever persists > 39 despite Rx)
– Monitor breathing – advised may help breathing to lie on the front or lie on the side if unable to lie on the front, rotate position every 2 hours front/side/sitting up
– Ask someone to check on you regularly
Safety netting [ Symptom based – safety netting template ]
– Discussed and advised to observe for specific red flags
– Call NHS 111 if: breathlessness on standing or moving – severe fatigue – rigors – oxygen saturations 93-94% – deteriorating
– Attend A+E or call 999 if: breathing suddenly worse – unable to complete short sentences – oxygen saturation 92% or less – chest pain or haemoptysis – collapse – confused or drowsy – not passing urine
– Understands to call or seek immediate medical review if any concerns

Copy and paste text into the notesUse windows short cuts to select the text (Ctrl + A), copy (Ctrl + C), and paste (Ctrl + V) into the clinical notes. <br><span style="color: yellow;"><b>If your clinical system is pasting the links use Ctrl+Shift+V (or Ctrl+V then press Ctrl button again and use T to select text only).</b></span>

COVID-19 Differential Diagnosis
SHOW COVID-19 Clinical reference links<b><u>KEY FOR LINKS</u></b><br><b>&uarr;</b> = will open in new tab <br><b>&darr;</b> = will open below (use Ctrl click to open in new tab) BMJ: Consult | Infographic | Best Practice
NHS London: Pathway | Rx @ home
COVID-19.PCN..: Triage | Symptom Mx