Diagnosis & management plan
Once you have completed the clinical assessment, this section allows you to formalise your findings and outline the next steps for the patient’s care.
1. Clinical Findings
In this section, you record your professional conclusion based on the history and observations captured earlier:
- Diagnosis: A clear statement of the confirmed condition.
- Differential Diagnosis: Note any other conditions you considered and subsequently ruled out during your assessment.
- Other Notes: Use this space for any additional clinical justifications or observations that support your final decision.
2. Management & Recommendations
The management plan defines the outcome of the consultation. You can log various types of advice or interventions here:
- Recommendations: A free-text area to detail the specific plan you have discussed with the patient.
- Recommendation 'Type': To help with pharmacy reporting and auditing, you will assign a category to your advice, such as:
- OTC Sale: Recommending a specific Over-The-Counter product.
- Clinical Advice: General healthcare guidance or self-care instructions.
- Referral to GP: Advising the patient to see their doctor for further investigation.
- Safety Netting: This is a critical safety step. Use this box to record exactly what advice you gave the patient regarding "red flag" symptoms and when they should seek urgent medical attention (e.g., "If symptoms worsen after 48 hours, contact 111").
3. Internal Referrals
If, during the consultation, you identify that the patient would benefit from another service offered by your pharmacy, you can use the Referral Tool.
- Select a Service: You will see a list of all PGD services currently enabled at your pharmacy.
- Automated Booking Link: If you select a service for referral, the system will automatically send the patient an email once the current consultation is submitted.
- Patient Journey: This email contains a direct link to book an appointment for that specific service, ensuring they don't have to search for it themselves later.
Clinical Tip: Building the Audit Trail
The management plan is often the most reviewed section during a clinical audit. Being clear and concise in your safety netting advice ensures that both you and the patient are protected.
