Pocket Dictation Booklet

Speak naturally. Mention only what is present. The system must not add normal findings unless dictated.

• Start with patient context: problem, current status, important changes.
• Say the template area aloud if needed: "fall risk", "PASS ICU", "handover".
• Use short findings: oxygen, lines, drains, mobility, feeding, urine, risk.
• For unknown details say: "not checked" or "to verify".
• Review the generated text before saving.

• 1:1 care indication or isolation requirement.
• Monitoring frequency and vital signs.
• Ventilator, NIV, HFNC, BiPAP, oxygen support.
• Vasoactive drugs or hemodynamic support.
• Central line, arterial line, epidural, EVD, drains.
• Dialysis, ICP monitoring, TPN, labs, dressings.
• Urine output, diuresis, GRBS or insulin infusion.
• Feeding route and lung therapy.

• Cognition: alert, confused, agitated, restrained.
• Mobility and fall risk.
• Medication load and IV infusions.
• Personal care dependency.
• Dressing frequency.
• Vital monitoring frequency.
• Skin integrity and elimination.
• Procedures, nutrition, oxygen, pain, lines and tubes.

• Reason for reassessment.
• Falls within 6 months or during admission.
• Post sedation, seizures, agitation, Parkinsonism, amputation.
• Age, elimination, high-risk medicines.
• Patient care equipment tethering.
• Mobility and cognition.
• Fall prevention bundle already applied.
• Education and supervisor escalation.

• Sensory perception.
• Moisture.
• Activity.
• Mobility.
• Nutrition.
• Friction and shear.
• aSSKINg bundle: assess, surface, skin, keep moving.
• Incontinence, nutrition, hydration, education.

• Active cancer or palliative treatment.
• Paralysis, paresis, plaster immobilization.
• Bedridden or major surgery.
• Deep vein tenderness.
• Entire leg swelling.
• Calf swelling, pitting edema, collateral veins.
• Previous DVT.
• Alternative diagnosis and doctor informed.

• Date and time.
• Eye opening.
• Verbal response.
• Motor response.
• GCS trend.
• Right and left pupil size / reaction.
• Pupil asymmetry.
• Limb power, speech, swallow and observation frequency.

• Neuro trend compared with previous shift.
• Headache, vomiting, seizure activity.
• Sensorium and behavior.
• Pain score.
• Feeding route and aspiration precautions.
• IV line, catheter, drain, tube.
• Restraint, fall risk, pressure prevention.
• Pending CT, MRI or review.

• Physical, chemical, or both.
• Indication and safety reason.
• Doctor order / authorization.
• Family or bystander informed.
• Alternatives attempted.
• Circulation and skin check.
• Release, range-of-motion, food, fluid, toileting.
• Need for continuation reviewed.

• From unit / bed and to unit / bed.
• Reason for transfer or movement.
• Time and escort.
• Vitals, oxygen, monitor, IV fluids.
• Lines, tubes, drains and infusions.
• Documents, consent, case sheet, reports.
• Belongings and handover.
• Return status if temporary movement.

• Source of admission.
• Presenting complaint and diagnosis.
• Allergy status.
• Vitals and pain score.
• Sensorium.
• Mobility and fall risk.
• Skin, nutrition, urine, bowel.
• Lines, tubes, drains, immediate plan, education.

• Care plan: assessment cues and active problem.
• Care plan: related factors and evidence.
• Care plan: expected outcome and interventions.
• Care plan: education, referral and evaluation.
• Handover: patient status.
• Handover: treatment, devices, investigations.
• Handover: pending tasks and safety watch.
• Handover: escalation plan for next shift.