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              📋 ON-CALL DOCUMENTATION TEMPLATE
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1. 📅 IDENTIFICATION
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[Date], [Time] — [Your Role]
Example: "May 28, 2025, 0230H – Resident On-Call Note"

2. ☎️ REASON FOR CALL
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Called by [Name/Role] at [Time] because:
"Patient [brief complaint/event]"
Example: "Called by RN at 0215H — patient found on floor."

3. ⏳ DELAY EXPLANATION (If any)
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If delayed: "Assessment delayed due to emergency in Room X."

4. 🩺 ADMISSION CONTEXT
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Brief summary of reason for admission and major conditions:
"[Age]-year-old with [key comorbidities], admitted for [primary issue]."

5. 🧾 HISTORY OF PRESENT ILLNESS (HPI)
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Narrative from patient and witnesses:
- What happened?
- Any symptoms?
- Witnessed or not?
- Vital signs at the scene?

Chart review (if applicable):
- Any similar past events?
- Relevant context.

6. 🔍 PHYSICAL EXAMINATION
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Focus ONLY on relevant systems.
Underline abnormal findings.

Vitals:
• BP: ___ mmHg   • HR: ___ bpm
• RR: ___        • SpO2: ___%
• Temp: ___ °C

HEENT:
• [Findings, e.g., No lacerations]

CVS:
• [e.g., Pulse regular, JVP X cm]

Musculoskeletal:
• [ROM, tenderness, swelling, hematomas]

Neuro:
• Alert/oriented? Reflexes? Sensory?

7. 🧪 INVESTIGATIONS
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Include only relevant labs/images:

Lab Values:
• Glucose: ___ mmol/L
• Creatinine: ___ mmol/L
• Abnormalities: ___

Imaging:
• [e.g., X-ray of left thigh pending]

8. 🧠 ASSESSMENT
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Synthesize a working diagnosis + differential:

Provisional Diagnosis:
1. [Primary cause of the event?]

Differential Diagnoses:
- [Alt. possibility 1]
- [Alt. possibility 2]

9. 📌 PLAN
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Immediate Actions Taken:
• [What you did during call/night]

Follow-Up/Orders for AM Team:
• [Tests, consults, etc.]

Communication:
• Informed [Intern/Resident/Attending] → [Summary of advice]
• Family updated? Yes/No – Summary of discussion

10. ✍️ SIGNATURE
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[Full Name, Title]
[Contact Info if needed]

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        ➤ Keep it PROBLEM-FOCUSED, CLEAR, and ACTIONABLE
        ➤ Underline abnormal findings to guide follow-up
        ➤ Don’t forget to record WHO, WHEN, and WHY
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