Patient consent recorded · Recording started · Template: Adult follow-up (SOAP)
Patient: The cough is three weeks now. Worse at night, and the blue inhaler only helps for an hour or so.10:04:51
Clinician: Chest is clear, a mild wheeze on expiry. Peak flow 360, you were 450 in March. Let's step up to the preventer and review in two weeks.10:09:30
Draft note ready. S: 3-week nocturnal cough, reliever relief ~1 hr. O: mild expiratory wheeze; PEF 360 (baseline 450). A: asthma, poorly controlled. P: start inhaled corticosteroid, review 2 weeks.10:12:08 · 38s
Suggested for review: asthma, unspecified (ICD-10 J45.909 or SNOMED CT equivalent) · follow-up task in 14 days · after-visit summary drafted. Not filed.10:12:09
Clinician edited 2 lines (added smoking status, inhaler technique checked) · Signed · Filed to EHR