Documentation Toolkit
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🧸 PEWS Sepsis Tool (U16 F2F)
☎️ 16yo+ (Tel)
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🤰 Preg/Post-Partum (F2F)
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👧 5-11yo (F2F)
☎️ Under 5yo (Tel)
👶 Under 5yo (F2F)
🦵 Wells DVT Score Calculator
Active cancer
Treatment or palliation within 6 months
No (0)
Yes (+1)
Bedridden recently >3 days or major surgery within 12 weeks
No (0)
Yes (+1)
Calf swelling >3 cm compared with the other leg
Measured 10 cm below tibial tuberosity
No (0)
Yes (+1)
Collateral (non-varicose) superficial veins present
No (0)
Yes (+1)
Entire leg swollen
No (0)
Yes (+1)
Localised tenderness along the deep venous system
No (0)
Yes (+1)
Pitting oedema, confined to symptomatic leg
No (0)
Yes (+1)
Paralysis, paresis, or recent plaster immobilisation of the lower extremity
No (0)
Yes (+1)
Previously documented DVT
No (0)
Yes (+1)
Alternative diagnosis to DVT as likely or more likely
No (0)
Yes (-2)
Total:
0
—
DVT unlikely
🫁 Wells PE Score Calculator
Clinical signs and symptoms of DVT
No (0)
Yes (+3)
PE is the most likely diagnosis, or equally likely
No (0)
Yes (+3)
Heart rate >100 bpm
No (0)
Yes (+1.5)
Immobilisation for ≥3 days or surgery in previous 4 weeks
No (0)
Yes (+1.5)
Previous objectively diagnosed PE or DVT
No (0)
Yes (+1.5)
Haemoptysis
No (0)
Yes (+1)
Malignancy
Treatment within 6 months or palliative
No (0)
Yes (+1)
Total:
0
—
PE unlikely
Consultation Type
-- Select consultation type (optional) --
Telephone Triage
Base Appt
Home Visit
Verification of Death - Home visit
NHS Records Access
Accessed with consent
Accessed in best interest
Seen with
-- Select person/role --
Alone
Brother
Carer
Daughter
Father
Husband
Mother
Other
Partner
Sister
Son
Wife
History taken from
(For third-party callers: Is patient at communication baseline?)
-- Select source --
Patient
Brother
Carer
Daughter
Father
Husband
Mother
Other
Partner
Sister
Son
Wife
A (Allergies)
M (Medications)
P (Past Medical History)
S (Social)
-- Residence --
Lives alone
Lives with
Residential home resident
Nursing Home resident
-- CFS --
1 Very fit
2 Well
3 Managing well
4 Vulnerable
5 Mildly Frail
6 Moderately Frail
7 Severely frail
8 Very severely frail
9 Terminally ill
-- Mobility --
Independent/Unaided
Stick
ZF
Wheelchair
Bedbound
Hoisted
HoPC
ICE
I: Ideas - What do you think might be going on?
C: Concerns - Is there something specifically worrying you about your symptoms?
E: What were you hoping I might be able to do for you today?
Obs, Neuro & Pain
RR (rpm)
SpO2%
Scale
Scale 1
Scale 2
Air or O2
on RA
on O2
BP (Sys/Dia)
HR (bpm)
ACVPU
A
C
V
P
U
Temp (°C)
Auto NEWS2 Score:
0
Neuro assessment - not included in NEWS2
PEARL
Not assessed
1mm
2mm
3mm
4mm
5mm
6mm
7mm
8mm
Lt Arm MMT
Not assessed
0 - No visible or palpable contraction
1 - Visible or palpable contraction without motion
2 - Full range of motion, gravity eliminated
3 - Full range of motion against gravity
4 - Full range of motion against gravity, moderate resistance
5 - Full range of motion against gravity, maximal resistance
Rt Arm MMT
Not assessed
0 - No visible or palpable contraction
1 - Visible or palpable contraction without motion
2 - Full range of motion, gravity eliminated
3 - Full range of motion against gravity
4 - Full range of motion against gravity, moderate resistance
5 - Full range of motion against gravity, maximal resistance
Lt Leg MMT
Not assessed
0 - No visible or palpable contraction
1 - Visible or palpable contraction without motion
2 - Full range of motion, gravity eliminated
3 - Full range of motion against gravity
4 - Full range of motion against gravity, moderate resistance
5 - Full range of motion against gravity, maximal resistance
Rt Leg MMT
Not assessed
0 - No visible or palpable contraction
1 - Visible or palpable contraction without motion
2 - Full range of motion, gravity eliminated
3 - Full range of motion against gravity
4 - Full range of motion against gravity, moderate resistance
5 - Full range of motion against gravity, maximal resistance
Speech
Not assessed
Normal speech
Slurred/Altered speech
Pain assessment - not included in NEWS2
Pain Score
Not assessed
0 - No pain
1 - Mild
2 - Mild
3 - Mild
4 - Moderate
5 - Moderate
6 - Moderate
7 - Severe
8 - Severe
9 - Severe
10 - Severe
Abbey Pain Score - not included in NEWS2
Abbey Pain Score
Not assessed
0 - No pain
1 - No pain
2 - No pain
3 - Mild pain
4 - Mild pain
5 - Mild pain
6 - Mild pain
7 - Mild pain
8 - Moderate pain
9 - Moderate pain
10 - Moderate pain
11 - Moderate pain
12 - Moderate pain
13 - Moderate pain
14 - Severe pain
15 - Severe pain
16 - Severe pain
17 - Severe pain
18 - Severe pain
Type not selected
Acute
Chronic
Acute on Chronic
EXAMINATION
IMPRESSION
PLAN
-- Common Rx --
Amoxicillin
Clarithromycin
Co-amoxiclav
Doxycycline
Flucloxacillin
Nitrofurantoin
PenV BD
PenV QDS
Pivmecillinam
Trimethoprim
Cipro/Dex Eardrops Both
Cipro/Dex Eardrops Left
Cipro/Dex Eardrops Right
Codeine
Naproxen
Omeprazole
Prednisolone
-- Plan Templates --
Abdo Pain (Adult)
Abdo Pain (Paeds)
Backache (Adult)
Cellulitis (Adult)
Chest Pain (Adult)
Conjunctivitis (Adult)
Conjunctivitis (Paeds)
Constipation (Adult)
Cough/Resp (Adult)
Cough/Resp (Paeds)
D&V/Gastroenteritis
Dental Pain / Toothache
Earache/OTM/OTE
Epistaxis
Fever (Adult)
Fever (Paeds)
Headache/Neuro (Adult)
Minor Burn / Scald (Adult and Paeds)
Minor Wound / Laceration Aftercare
Pyelonephritis
Sciatica / Lumbar Radiculopathy (Adult)
Soft Tissue Injury / Sprain (Adult)
Testicular
Throat (Adult)
Throat (Paeds)
Urticaria / Hives (Adult)
UTI (Adult Female)
UTI (Adult Male)
UTI (Child Female)
UTI (Child Male)
-- Red Flags --
Abdo Pain (Adult)
Abdo Pain (Paeds)
Allergic Reaction/Anaphylaxis
Asthma (Adult)
Asthma (Paeds)
Back Pain (Adult)
Cellulitis (Diagnosed) (Adult)
Cellulitis (Diagnosed) (Paeds)
Chest Pain (Adult)
Chest Pain (Paeds)
Cold/Flu/URTI (Adult)
Cold/Flu/URTI (Paeds)
COPD (Adult)
Cough (Adult)
Cough (Paeds)
Diarrhoea and/or Vomiting (Adult)
Diarrhoea and/or Vomiting (Paeds)
Dizziness/Vertigo (Adult)
Earache (Adult)
Earache (Paeds)
Eye Problems (Adult)
Eye Problems (Paeds)
Fatigue/TATT (Adult)
Fatigue/TATT (Paeds)
Fever (Adult)
Fever (Paeds)
Head Injury (Adult)
Head Injury (Paeds)
Headache (Adult)
Headache (Paeds)
Insect Bites/Stings (Adult)
Insect Bites/Stings (Paeds)
Limb Injury (Adult)
Limb Injury (Paeds)
Mental Health Issues (Adult)
Mental Health Issues (Paeds)
Neurological Presentation (Adult)
Neurological Presentation (Paeds)
Nosebleed (Epistaxis) (Adult)
Rash (Adult)
Rash (Paeds)
Sepsis / Undifferentiated Severe Illness
Sore Throat (Adult)
Sore Throat (Paeds)
Testicle
UTI Female (Adult)
UTI Male (Adult)
UTI (Paeds)
Wound (Adult)
Wound (Paeds)
Pre-Visit Information
(Complete this when allocating pt for a home visit)
Documentation Toolkit Version 5.3.38 GEN Last updated: 12 August 2026
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