(Use New Zealand spelling of medications) (Do not use patient name, date of birth, or identifiers) (If an issue is mentioned at the end of the consult transcript, the note should be written with the first section containing history of each issue/problem, second section containing examination, third section containing assessment, and fourth section containing plan) (Do not insert sections for PHx, FHx or SHx) (Do not insert examination findings into the body of the issue/problem, only insert one time in the physical examination section) (Any relevant past medical history, family history or social history should be listed underneath the relevant issue/problem, not in it's own section) (Use a maximum of 6 bullet points for HOPC for each Issue/Problem. Symptoms can be separated by commas under the same bullet point.) (Combine related symptoms under single problem heading, e.g. Cough and Fever) [1st Issue, problem, or request 1 (issue, request or condition name only)](If unsure or under investigation precede issue/problem with "?") (Do not insert a space after heading)- [history related to 1st presenting complaint] (Each new line should start with a lower case letter) [If relevant 2nd Issue, problem, or request 2 (issue, request or condition name only)] - [history related to 2nd presenting complaint] (Each new line should start with a lower case letter) [If relevant 3rd, 4th, 5th Issue, problem, or request 3/4/5 (issue, request or condition name only)] - [history related to subsequent presenting complaint] (put related symptoms onto same line separated by commas, rather than starting new lines. Each new line should start with a lower case letter) oe (physical examination should be in following order, ONLY if mentioned during consult, otherwise not inserted: blood pressure, weight, general disposition, Ear nose and throat, heart/cardiovascular, chest/respiratory, abdomen, other) (if relevant, blood pressure should be written on it's own line with "\bp " in front, e.g. 120/80 should be "\bp 120/80") (if relevant, weight should be written on it's own line with "\wt " in front, e.g. 80kg should be written without units as "\wt 80") (if relevant, temp, O2 sats, and HR should all be documented on the same line) [Physical or mental state examination findings, including vitals and system specific examination] (only include if applicable, and use as many bullet points as needed to capture the examination findings) (Only put examination findings in once) (If respiratory illness and looking clinically well should be documented as: "Looks well, nil increased WOB") (Normal cardiac exam should be documented as: "HSD nil murmurs - regular") (Normal respiratory exam should be documented as: "Chest clear and equal - no creps or wheezes") (Normal ear exam should be documented as: "Ears: R) normal canal, TM nad, L) normal canal, TM nad") (Normal abdominal exam should be documented as: "Abdo SNT, no signs peritonism. Nil organomegaly. Nil masses. Nil flank tenderness.") Imp: [Issue 1 (issue, request or condition name only)], [Assessment, likely diagnosis for Issue 1 (condition name only)], [Differential diagnosis for Issue 1 (only if applicable)] - [Issue 2 if relevant (issue, request or condition name only)], [Assessment, likely diagnosis for Issue 2 (condition name only)], [Differential diagnosis for Issue 1 (only if applicable)] - [Issue 3 if relevant(issue, request or condition name only)], [Assessment, likely diagnosis for Issue 3 (condition name only)], [Differential diagnosis for Issue 1 (only if applicable)] Plan: - [Investigations planned for Issues (only if applicable)] (don't list individual blood tests) - [Treatment planned for Issues (only if applicable)] (don't list individual regular medications for repeat in no changes, just state regular medicines repeated) - [Relevant referrals for Issues (only if applicable)] (if relevant move issue at bottom of notes to fit normal structure, merge plans) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that it has not been mentioned and instead leave the relevant placeholder blank.)