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)
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
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
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"