A day-one ward review, spoken at the bedside
A laparoscopic appendicectomy at Merrigal Private Hospital, reviewed the morning after surgery, through to the GP letter at discharge.
The review and the draft note
What the surgeon said
Gallagher, Claire · 34F · DOB 14/03/1992 · Bed 8 · Synthetic patient
Ward round, Claire Gallagher, bed eight. Day one after laparoscopic appendicectomy yesterday afternoon. Inflamed appendix, not perforated, no free fluid. Comfortable night. Pain three out of ten on regular paracetamol, one dose of oxycodone five milligrams at two a.m. Tolerating a light diet, no nausea. Passing flatus, voiding, mobilising on her own.
Obs: afebrile at thirty-six eight, heart rate seventy-eight, BP one eighteen on seventy-two, sats ninety-eight percent on room air.
Abdomen soft, tender at the port sites only, no guarding. Three port sites clean and dry. Calves soft.
Bloods this morning: white cell count nine point two, down from fourteen point eight on admission. CRP forty-one.
Impression: uncomplicated day one recovery.
Plan: home today. No further antibiotics. Paracetamol one gram four times a day as needed, and ibuprofen four hundred three times a day with food as needed for three days. Dressings off on day five, she can shower. No heavy lifting for two weeks. Histology is pending, I'll send it to the GP. Review in rooms in two weeks. Discharge summary and a letter to her GP, Doctor Hartley.
The GP letter and the billing item
The GP letter carries the discharge summary inline, on the practice letterhead.
The film
The same admission in the app, from the ward board to the audit log.
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