Endocrinology template

Endocrinology notes, written while you talk

Diabetes and thyroid clinics are about trends and screening. The Endocrinology template records glycaemic control, hypoglycaemia, endocrine results and what complication screening is done or due.

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Built for a Endocrinology clinic

The consultations this template is laid out for, among others:

  • Type 2 diabetes
  • Type 1 diabetes
  • Hypothyroidism
  • Hyperthyroidism
  • Obesity
  • Polycystic ovary syndrome

See a Endocrinology note

A short consultation in Urdu, and the note Hikayat Scribe writes from it.

The consultation (Urdu)

Doctor: Sugar kaisi hai?

Patient: Subah 180 ke aas paas aati hai.

Doctor: HbA1c 8.9 hai. Kabhi sugar low hui?

Patient: Nahi.

Doctor: Metformin 1000 do dafa chal rahi hai. Gliclazide add kar rahe hain, teen mahine baad HbA1c.

The note

Glycaemic control
HbA1c 8.9%. Fasting home readings around 180 mg/dL. Denies hypoglycaemia.
Drug history
Metformin 1000 mg BD.
Plan
Add gliclazide. Repeat HbA1c in 3 months.

Fictional patient. Sections that were not discussed are left off.

What the Endocrinology template records

Alongside the usual history and examination, every Endocrinology note has these sections:

Glycaemic controlEndocrine resultsComplication screeningWeight and lifestyleInsulin techniquePain assessmentPatient education

Only what was discussed

Screening is never marked as done or normal unless someone said so. Any section that was not covered is simply left off the note, so it never fills up with "not discussed".

Set it once

Choose Endocrinology when you start a clinic or ward note, or tick "Always start my notes with this specialty" and it stays selected until you change it. Specialty templates are part of Pro and Enterprise, and included in the 7-day free trial.

The rest of the note

  • Ranked differentials with the reasoning shown, for you to choose from
  • Investigations and medicines you tick yourself; nothing is prescribed until you do
  • ICD-10 and SNOMED codes for your review
  • Your name, qualifications, registration number and the date and time on the printed note

How it works

  1. Record. Press the button and talk with your patient in any of nine languages, or dictate on your own.
  2. Review. The note is ready in seconds. Tick the diagnosis, investigations and medicines you are keeping, and edit anything.
  3. Use it. Copy, print or email the note, with your name, qualifications and registration number on it.

Common questions

Will it mark eye and foot screening as done?
Only if it was said in the consultation. Otherwise the screening section stays off the note.
Can it follow insulin dose changes?
Yes. Doses and injection technique are recorded as discussed.
Can I use the Endocrinology template for ward notes?
Yes. Specialty templates work for outpatient clinic notes and inpatient ward notes.
What if I also have my own template?
Both are used together: your own sections first, then the specialty sections.

Related

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