SPP1 Electronic Patient Record

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Patient Details & Admission

Personal information

Full name

Date of birth

NHS number

Gender

Address

Admission details

Reason for admission / referral

Date of admissionWard / Team

Lead clinician / consultant

Allergies / adverse reactions

Medical, social & family history

Past medical history

Current medications on admission

Social history

Family history

Saved ✓

NEWS2 Observation Chart

Date

Time

Student initials

RGN countersign

Observation	Result	Score
Respiratory rate (breaths/min)		—
SpO₂ Scale 1 (%)		—
Air or supplemental O₂?		—
O₂ flow rate (L/min)		—
Systolic BP (mmHg)		—
Diastolic BP (mmHg)		—
Pulse / heart rate (bpm)		—
Consciousness (ACVPU)		—
Temperature (°C)		—

NEWS2 Total Score

—

RED ALERT — single parameter score ≥ 3

Comments / actions taken

Saved ✓

MUST — Malnutrition Universal Screening Tool

Date of assessment

Assessed by

Step 1 — BMI score

Current weight (kg)

Height (m)

BMI (auto-calculated)

Step 2 — Weight loss score

Weight 3–6 months ago (kg)

% weight loss (auto)

Step 2 score

Step 3 — Acute disease effect

Acutely ill & likely no nutritional intake >5 days?

BMI score

—

Wt loss score

—

ADE score

—

MUST Overall Score

—

Management plan / actions

Saved ✓

24-Hour Fluid Balance Chart

Date

Completed by

Countersigned

Target daily balance (ml)

Time	Oral (ml)	IV Fluids (ml)	Enteral (ml)	Blood (ml)	IV Meds (ml)	Other In (ml)	Urine (ml)	Stool (est.)	Vomit/NG (ml)	Drains (ml)	Other Out (ml)	Balance (ml)
TOTAL	0	0	0	0	0	0	0	0	0	0	0	0

Record volumes in ml. Running balance is cumulative intake minus output. Positive = net fluid gain. Negative = net fluid loss. Consider weight trends and clinical context.

Saved ✓

Neurological Observations & Glasgow Coma Scale (GCS)

Date

Time

Assessed by

Countersigned

GCS components

Eye opening (E) — max 4

Verbal response (V) — max 5

Motor response (M) — max 6

GCS Total

—

Pupils & limbs

L pupil size (mm)

L pupil reaction

R pupil size (mm)

R pupil reaction

R arm movements

L arm movements

R leg movements

L leg movements

Comments / clinical findings

Saved ✓

Inpatient Medication Prescription & Administration Record

For educational use only — not for clinical use

Allergies / adverse reactions

High-risk flags

Weight (kg)

Renal dose adjustment needed?

VTE prophylaxis reviewed?

Opioid conversion checked?

Regular medications

Medicine	Form/Strength	Dose	Route	Frequency	Indication	Start date	Stop date	Prescriber

PRN / once-only medications

Medicine	Form/Strength	Dose	Route	Max in 24h	Indication	Start date	Prescriber

Signature log

Student initials

Student full name

Supervising RGN initials

Supervising RGN full name

Saved ✓

iSBAR Clinical Handover Template

Date / time of handover

Handing over to

i — Introduce

S — Situation

B — Background

A — Assessment

R — Recommendation

Read-back / response from recipient

Saved ✓

Pain Assessment

Date

Time

Assessed by

Countersigned (RGN)

NRS (self-report)

Abbey Pain Scale

PAINAD (dementia)

SOCRATES history

Numeric Rating Scale (NRS-11) — standard self-report tool used across NHS trusts. Ask the patient: "On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, how would you rate your pain right now?"

0 — No pain5 — Moderate10 — Worst imaginable

Selected score

—

Pain at rest (NRS)

Pain on movement (NRS)

Worst pain in 24h (NRS)

Abbey Pain Scale — validated for patients who cannot self-report pain (e.g. advanced dementia, severe communication difficulties). Observe the patient and score each of the 6 indicators 0–3.

Abbey total score

No pain (0)

PAINAD Scale (Pain Assessment in Advanced Dementia) — observe the patient for 5 minutes. Select the descriptor that best matches what you observe for each of the 5 domains. Total score 0–10.

Domain

Score 0

Score 1

Score 2

PAINAD total score

No/minimal pain

SOCRATES structured pain history

S — Site: where is the pain?

O — Onset: when did it start? Sudden or gradual?

C — Character: what does it feel like?

R — Radiation: does it spread anywhere?

A — Associated symptoms

T — Time course / pattern

E — Exacerbating & relieving factors

S — Severity (current NRS score)

Pain management & response to treatment

Current analgesic(s) prescribed

Last analgesia given

Non-pharmacological interventionsHold Ctrl / Cmd to select multiple

Re-assessment NRS (post-intervention)

Time of re-assessment

Escalation required?

Notes / further actions

Saved ✓

Clinical Notes

Date

Time

Written by

Countersigned

Assessment / findings

Plan / interventions carried out

Evaluation / response to care

Saved ✓

SPP1 2026/27 — 11-Week Unit Planner with SimConverse & EPR Integration

SimConverse AI patient consultation before EPR task EPR tab Click to navigate to that tab Gap Activity not yet in EPR

Gap analysis — activities from the unit plan not fully covered by current EPR tabs

The following sessions are not yet represented and could become future EPR tabs: ADL / Nursing Process assessment (week 1); IPC / hand hygiene record (week 2); Manual handling risk assessment (week 3); Medication administration / SafeMedicate log (weeks 5–8); Elimination / continence assessment and urinalysis (weeks 8 & 10); Mouthcare / personal care record and ANTT documentation (week 9); A–E assessment framework (week 10); Wound / dressing assessment (week 11).