mohitagw15856
84 lines
2.7 KiB
Markdown
84 lines
2.7 KiB
Markdown
---
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name: clinical-case-summary
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description: "Write a structured clinical case summary or case presentation. Use when asked to write a clinical case summary, case presentation, patient case report, or clinical handover. Produces a structured summary using SBAR or SOAP format. For educational and documentation purposes only — not a substitute for clinical judgement."
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---
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# Clinical Case Summary Skill
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Produces structured clinical case summaries for educational, documentation, and handover purposes.
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WARNING: For documentation and educational purposes only. All clinical content must be reviewed by a qualified healthcare professional. This is not clinical advice.
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## Required Inputs
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- **Purpose** (case presentation / handover / case report / educational / MDT summary)
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- **Patient details** (anonymised — age, sex, relevant background)
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- **Presenting complaint and history**
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- **Examination findings**
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- **Investigations and results**
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- **Diagnosis or differential diagnoses**
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- **Management and treatment**
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- **Outcome** (if known)
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- **Format preference** (SBAR / SOAP / Standard clinical / Narrative)
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---
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## Format A: SBAR (Handover / Referral)
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**S — Situation**
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[Patient identifier anonymised, location, reason for contact in one sentence]
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**B — Background**
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- Age / sex / relevant past medical history
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- Current admission details
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- Relevant medications and allergies
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- Brief relevant social history
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**A — Assessment**
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- Current clinical status
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- Vital signs if relevant
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- Key examination findings
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- Working diagnosis or differential
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- Recent investigations and results
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**R — Recommendation**
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- What you need from the recipient
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- Urgency level
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- Immediate actions already taken
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- Questions or concerns
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---
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## Format B: SOAP Note
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**S — Subjective**
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[Presenting complaint in patient words. Symptom history: onset, duration, character, severity, associated symptoms, relieving/aggravating factors]
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**O — Objective**
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- Vital signs: [BP, HR, RR, Temp, O2 sats]
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- Examination: [Systematic findings]
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- Investigations: [Results with reference ranges]
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**A — Assessment**
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- Primary diagnosis: [With brief rationale]
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- Differential diagnoses: [Ranked with reasoning]
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**P — Plan**
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- Immediate management
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- Investigations ordered
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- Treatments initiated with dose, route, frequency
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- Referrals
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- Safety netting: what to watch for, when to escalate
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- Follow-up plan
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## Quality Checks
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- Patient details fully anonymised
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- Allergies and medications included in handover formats
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- Safety netting included in SOAP plan
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- Disclaimer included
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## Example Trigger Phrases
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- "Write a clinical handover using SBAR for this patient"
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- "Summarise this case in SOAP format"
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- "Write a case report for [clinical scenario]"
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- "Prepare an MDT summary for this patient"
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