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Kit klinische Dokumentation

Klinischer Alltag: Anamnese und Befund, SOAP, Verlaufs- und OP-Berichte, SBAR, I-PASS, Überweisung, Medikationsabgleich, Entlassung.

11 Vorlagen in 4 Schritten, in der Reihenfolge der Nutzung. Öffnen Sie eine Vorlage im Editor, füllen Sie sie aus und exportieren Sie sie als PDF, DOCX oder HTML.

Schritt 1

Bewertungen

  1. History and Physical (H&P) Template

    Standard

    History and physical note: chief complaint, OLDCARTS HPI, histories, review of systems, exam by system, differential, plan

  2. SOAP Note Template

    Standard

    Problem-oriented SOAP note: subjective, objective, numbered problem assessment, plan per problem, follow-up and safety-netting

    Problem-oriented medical record (Weed, 1968)

  3. Progress Note Template

    Kompakt

    Daily progress note: interval history, vitals with trend, exam, results, assessment and plan by problem, signature

  4. Operative Note Template

    Standard

    Operation or procedure note: details, team, findings, steps, specimens and implants, complications, prophylaxis, postoperative orders, checklist

    RCS England Good Surgical Practice 2025, section 3.5
Schritt 2

Kommunikation

  1. SBAR Handoff Template

    Standard

    SBAR and ISBAR clinical handoff: identify, situation, background, assessment, request with time frame, closed-loop read-back, outcome

    SBAR (IHI; AHRQ TeamSTEPPS 3.0), ISBAR variant

  2. I-PASS Shift Handover Template

    Standard

    Shift handover by I-PASS: unit overview, illness severity, patient summary, action list, contingencies, receiver synthesis, completion checks

    I-PASS (Starmer et al., N Engl J Med 2014)

  3. Clinical Referral Letter Template

    Kompakt

    Referral letter: referrer and recipient, urgency, question for specialist, history, medications, investigations, attachments

Schritt 3

Übergänge in der Versorgung

  1. Medication Reconciliation Form Template

    Standard

    Admission, transfer and discharge med rec: patient alerts, sources, best possible medication history, comparison with orders, discrepancy types and resolution

    WHO High 5s Medication Reconciliation Implementation Guide v4 (2014)

  2. Discharge Summary Template

    Standard

    Hospital discharge summary: diagnoses, course, alerts and safeguarding, devices, legal and capacity, medication reconciliation, risks and VTE plan, follow-up, pending results

    Maps to PRSB eDischarge Summary (UK); 42 CFR 482.43 (US); Joint Commission RC (cited)

  3. Nursing Care Plan Template (ADPIE)

    Standard

    Nursing care plan by the nursing process: assessment, diagnoses (problem, etiology, signs), SMART goals, interventions, evaluation

    Nursing process (ADPIE)
Schritt 4

Lernen

  1. Clinical Case Report Template

    Vollständig

    Case report by CARE topics: de-identified patient information, timeline, diagnostic reasoning, outcomes, patient perspective, consent

    CARE guidelines