Supervisor (coded)
Your role eg student, Resident doctor, Nurse etc
Context: eg clinic, IT issues, telephone, pandemic
PC
HPC
Modifiers (triggers, relievers)
Associated symptoms
Risk factors
Red flags/Alarm features
Systems enquiry
ICE:
PMH
DH including over the counter:
Allergy
FH
SH
Summary of case
Impression
Differential diagnosis
list of issues including ethics
Discussions with supervisor
Actions
Communication to patient
What as not communicated