Does it calculate pack-years?

No. It records smoking exactly as the patient describes it, and you can add the pack-year figure yourself.

Will it assign a GOLD stage?

Only if you state one. Staging and grading are never inferred.

Can I use the Pulmonology 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.

Pulmonology template

Pulmonology notes, written while you talk

Chest clinic notes need smoking, exposures, TB history and inhaler use recorded properly. The Pulmonology template does exactly that, alongside SpO2, exacerbations and the results you review.

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Built for a Pulmonology clinic

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

COPD
Asthma
Chronic cough
Tuberculosis follow-up
Interstitial lung disease
Sleep-disordered breathing

See a Pulmonology note

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

The consultation (Urdu)

Doctor: Khansi kab se hai?

Patient: Teen mahine se, balgham ke saath, subah zyada. Seedhiyan chadhne pe saans phoolti hai.

Doctor: Sigarette? Aur ghar mein chulha?

Patient: Roz bees, pachees saal se. Ghar mein lakdi ka chulha hai.

Doctor: Oxygen 93 percent room air pe. Dono taraf wheeze hai. Spirometry karwate hain.

The note

Presenting complaint: Productive cough x3/12, exertional breathlessness.
History: Cough with sputum, worse in the mornings. Breathless on climbing stairs.
Examination: Bilateral wheeze.
Smoking and exposures: Smokes 20/day for 25 years. Biomass smoke exposure (wood-fired stove at home).
Vital signs: SpO2 93% on room air.
Plan: Spirometry.

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

What the Pulmonology template records

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

Smoking and exposuresTB history and contactsVital signsInhalers and oxygenExacerbationsResults reviewedPain assessmentPatient education

Only what was discussed

It never works out pack-years or assigns an MRC grade, GOLD stage or asthma control level unless you say one. Any section that was not covered is simply left off the note, so it never fills up with "not discussed".

Set it once

Choose Pulmonology 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

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

Common questions

Does it calculate pack-years?: No. It records smoking exactly as the patient describes it, and you can add the pack-year figure yourself.
Will it assign a GOLD stage?: Only if you state one. Staging and grading are never inferred.
Can I use the Pulmonology 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.

Better notes start today.

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