Summary: - (generate a brief overview of the consultation below in 2 or 3 sentences. Use paragraph format. Include details from history, examination, and plan, highlighting any necessary actions.)
[face to face “F2F” OR if calling via telephone “T/C”] [indicate if anyone else is present, e.g., “seen alone” or “seen with…” (based on introductions). ‘[Reason for visit, e.g., current issues, presenting complaint, booking note, or follow-up]’.
Consent:
- [record verbal consent for the use of AI Scribe software to document the consultation] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
History:
- [History of presenting complaints, including timeframes of complaint (if explicitly mentioned)]
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints, etc.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [If pain history, describe using the SOCRATES structure for a pain history for those elements mentioned]
- [Presence or absence of red flag symptoms relevant to the presenting complaint]
- [Relevant risk factors]
- [PMH: / PSH: - include past medical history or surgical history (if applicable)] (please format this on one line as a list)
- [DH: Drug history/medications (if mentioned)]. [Allergies: (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] (please format this on one line as a list)
- [FH: Relevant family history (if applicable)] (please format this on one line as a list)
- [SH: Social history, i.e., lives with, occupation, smoking/alcohol/drugs, recent travel, carers/package of care (if applicable)] (please format this on one line as a list)
Relevant Investigation results
- [Investigations with results (if applicable)] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [Document relevant blood results prior to consultation] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [Document imaging results (e.g., X-Rays, CT scans, MRI scans)] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [Document urine dipstick result in terms of blood, nitrites, and leucocytes] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Examination:
- [describe general appearance] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [document vital signs on the same line as: Temp, Sats %, HR (and if regular or irregular, if explicitly mentioned), BP mmHg, RR,] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from cardiovascular examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from respiratory examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from abdominal examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from head and neck examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from musculoskeletal examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from neurological examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe findings from skin examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Diagnosis:
1. [list primary diagnosis] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
2. [list secondary diagnoses] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
3. [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Plan:
- [describe treatment plan, including medications, therapies, and lifestyle modifications] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe follow-up plans and referrals] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [mention patient education and counselling provided] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [mention any diagnostic tests or procedures ordered] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- [describe safety netting advice] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
(Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc. - use only the transcript, contextual notes, or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)