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The report sections

The form runs roughly in the order you would work a call. Every section carries its own free-text field, and most support custom options you add yourself.

Presenting Complaint​

What the patient or caller says is wrong, in their terms. Any ingestions you recorded in the toolbox surface here read-only — you edit them in the tool, but they are visible in context.

Scene & Arrival​

Scene details, times and what you found on arrival. Custom options are supported, so the scene descriptors your service actually uses can be added once and reused.

Primary Survey​

Catastrophic haemorrhage and ABCDE:

  • <C> Catastrophic haemorrhage
  • A Airway
  • B Breathing
  • C Circulation
  • D Disability — with an integrated GCS calculator scored by E/V/M component
  • E Exposure

Each of the six carries its own custom options and free text.

The GCS is scored by component, never as a remembered total. Until all three components are set there is no sum — a part-scored GCS prints its components rather than a fabricated total.

Consent & Capacity​

Capacity assessment and consent recording. In the Mental Health presentation this sits alongside Mental Capacity Act assessment.

Detailed Examination​

Per-system examination with tri-state findings and per-system notes:

  • Cardiovascular
  • Respiratory
  • CNS
  • GI / GU
  • ENT
  • Skin
  • MSK
  • Mental Health (in the relevant presentation)

In the Cardiac Arrest presentation this is replaced by cardiac-specific history and examination following the ALS structure.

Observations​

Repeatable, timestamped sets of vital signs, each scored for NEWS2. This is the largest single feature in the app and has its own page.

Social History​

Living situation, mobility, support and function — plus the Clinical Frailty Scale, which produces a baseline frailty line for the report and feeds the AI tools.

Clinical History​

  • History of presenting complaint
  • Past medical history — conditions, with custom options
  • Medications and allergies

Plan & Outcome​

Disposition, treatment given, referral pathway and safety-netting advice. Treatment is chosen through a picker rather than typed, and the Rx and Plan & Outcome option lists are both extensible.

The ATMIST pre-alert is launched from here — see ATMIST pre-alert.

Referral​

The referral pathway and the detail that goes with it, for onward care.

Things that are true of every section​

Nothing is mandatory. MedJot never blocks you from finishing a report because a field is empty. An empty field simply prints nothing.

Free text is always available. If the options do not cover it, write it.

Your own options can be added inline. See Custom options.

Order in the report follows the section order, not the order you filled things in — so you can jump around during the call and still get a conventionally structured record.