Write a structured clinical case summary or case

Clinical Case Summary Skill

Produces structured clinical case summaries for educational, documentation, and handover purposes.

WARNING: For documentation and educational purposes only. All clinical content must be reviewed by a qualified healthcare professional. This is not clinical advice.

Required Inputs

• Purpose (case presentation / handover / case report / educational / MDT summary)
• Patient details (anonymised — age, sex, relevant background)
• Presenting complaint and history
• Examination findings
• Investigations and results
• Diagnosis or differential diagnoses
• Management and treatment
• Outcome (if known)
• Format preference (SBAR / SOAP / Standard clinical / Narrative)

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Format A: SBAR (Handover / Referral)

S — Situation [Patient identifier anonymised, location, reason for contact in one sentence]

B — Background

• Age / sex / relevant past medical history
• Current admission details
• Relevant medications and allergies
• Brief relevant social history

A — Assessment

• Current clinical status
• Vital signs if relevant
• Key examination findings
• Working diagnosis or differential
• Recent investigations and results

R — Recommendation

• What you need from the recipient
• Urgency level
• Immediate actions already taken
• Questions or concerns

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Format B: SOAP Note

S — Subjective [Presenting complaint in patient words. Symptom history: onset, duration, character, severity, associated symptoms, relieving/aggravating factors]

O — Objective

• Vital signs: [BP, HR, RR, Temp, O2 sats]
• Examination: [Systematic findings]
• Investigations: [Results with reference ranges]

A — Assessment

• Primary diagnosis: [With brief rationale]
• Differential diagnoses: [Ranked with reasoning]

P — Plan

• Immediate management
• Investigations ordered
• Treatments initiated with dose, route, frequency
• Referrals
• Safety netting: what to watch for, when to escalate
• Follow-up plan

Quality Checks

• Patient details fully anonymised
• Allergies and medications included in handover formats
• Safety netting included in SOAP plan
• Disclaimer included

Anti-Patterns

• Do not include any identifiable patient information — full names, dates of birth, NHS or MRN numbers, or specific addresses must be anonymised or replaced with generic identifiers
• Do not omit the clinical disclaimer — this output is for documentation and educational purposes only and must not be presented as clinical advice
• Do not confuse the SBAR Recommendation with a treatment plan — R is what you need from the recipient, not a full management plan
• Do not list differential diagnoses without noting the reasoning for ranking — an unranked list of differentials is not clinically useful

Example Trigger Phrases

• "Write a clinical handover using SBAR for this patient"
• "Summarise this case in SOAP format"
• "Write a case report for [clinical scenario]"
• "Prepare an MDT summary for this patient"