Patient Notes

Patient's details (Please print)
Full name GREY ~~(UNKNOWN)~~ NICK
Gender F ☑ / M ☐
Species Earth ☐ / Pegasus ☑ / Unicorn ☐ / Other ☐
Date of birth N/A (AGE APPROX. 12 YRS)
Contact N/A
Home Address N/A
GP and Surgery DOCTOR HORSE

Patient Note

• 4CM LONG CUT LEFT SIDE UNDER EYE. STITCHES APPLIED
• SEVERE LACERATIONS TO RHL. TIMBERWOLF. STITCHES
• NURSE NOTED PATIENT SLEPT FOR OVER 14HRS, AWOKE DISORIENTED
• ~~FRIGHTENED HELPING HOOF~~ ALLERGY MORPHINE, SUSPECT ALL OPIATES
• DEMANDED CLOTHING. SELF HARM SCARS OBSERVED, WILL QUESTION LATER
• COMMUNICATION SKILLS LOW, SPEECH IMPEDIMENT. SEEMS TO UNDERSTAND, TROUBLE EXPRESSING

Objective Notes

• CURRENT MEDICATION - PARACETAMOL
• OBSERVE AND REPORT
• POSSIBLY SEND FOR PSYCHIATRIST/PSYCHOLOGIST
• CONTACT CPS
• PATIENT NEEDS TO FEEL COMFORTABLE. ASSIGN HELPING HOOF TO HER.

This information may be shared with external agencies: Yes ☑ / No ☐
This information may be shared when attached to a case: Yes ☑ / No ☐

This information should be reviewed on......12/10/1010........ (date)

Signed: D.Horse
Print name: Doctor Horse

Surgery: 10/10/1010
Date: 11/10/1010

Please return during office hours to:
Admin, Ponyville General Hospital, Ponyville.

Author's Note

Looked at templates online. Tried to combine a Patients Notes and a Progress Report. Hopefully the basic gist gets across anyway.