Description: The Checklist Medical Considerations is optional.

It is added to support the clinician in charge of the patient to have an overview of the current medical problems, the diagnostic considerations and treatments. In the following the fields will be described. It is an example for its use. However the fields can be adjusted to the specific needs of local practices.

Reason for referral/admission

Here the reason for referral/admission is described on a symptom/problem-level. For instance: Shortness of breath and fever.

Working diagnosis

Here the diagnoses are described, including psychiatric, which are supposed to be the reason for referral/admission and will be elaborated during the clinical investigations. For instance: pneumonia or delirium.

Secondary diagnosis related to working diagnosis

Here the diagnoses a patient is known with are documented which might interfere with the current illness episode and might require adjustment. Fore instance chronic heart failure.

"Inactive diagnosis"

Here diagnoses are mentioned which are not focus of active treatment but are mentioned as they might be important for rehabilitation or should not be forgotten. For instance Left sided stroke with right sided functional impairment or amputation of lower left leg.

Diagnostic action

Here the diagnostic lines can be described related to the different working diagnosis.

Therapy

Here the therapeutic lines related to the working and other diagnoses can be described.

Therapeutic restrictions

Here the level of therapeutic restrictions can be coded.

Medication

Here current medication can be described.

Expected LOS

Here in case of clinical admissions a prognosis can be made about the expected length of hospital stay.

Messages for physicians on call

Here pertinent messages can be documented for clinicians on call.