[(If transcript starts with words of 'calling from', 'calling you' 'phoning you', 'ringing you', 'buzzing you', print: ‘Telephone consult, Spoke with- patient', otherwise, print: face to face “F2F consult”) (If mentioned relationship to patient, print: relationship of the person in brackets) (If mentioned 'online request', 'accurx request', 'gp consult', 'e consult' print: 'in context to above online request'.) (If mentioned 'seen colleague', 'spoke to colleague', 'seen clinician', 'spoke to clinician', 'seen nurse', 'spoke to nurse', 'seen ANP', 'spoke to ANP', print: 'in context to previous consult dated-'.) (If mentioned 'letter', 'email', 'communication from', 'message', 'task', print: 'in context to comms and letters dated-'.) (If mentioned 'spoke to me', 'seen me', 'I saw you', 'I spoke with you', 'I called you', print: 'in context to my previous consult dated-'.)] [Write a clinically relevant summary of the consultation. Include clinically relevant information from History, Patient's Ideas, Concerns and Expectations, Presence or absence of red flag symptoms relevant to the presenting complaints, Relevant risk factors, Past medical history or Surgical history, Drug history/Medications, Allergies (include only if applicable and explicitly mentioned otherwise leave blank), Relevant family history, Social history (include all family and social history in a single sentence, separated by a 'comma ,').] [Past Investigations with results (do not include investigations planned in the future) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (do not duplicate mode of visit such as ‘telephone consultation’ or ‘F2F’ again) Examination: [do not include this section in a Telephone consult, except when there is a mention of how the patient sounds (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank] [Vital signs listed, eg. Temperature , oxygen level or Sats %, HR , BP , RR , blood glucose/blood sugar/BM (only include for 'F2F' visit or consultation if applicable and explicitly mentioned and expressed as 'numericals' otherwise leave blank)] [Physical or mental state examination findings, including system specific examination (only include for 'F2F' visit or consultation, otherwise leave blank)] Impression: [Issue, problem or request 1, 2, 3, 4, 5 etc (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 1, 2, 3, 4, 5 etc (condition name only) (include only if applicable and explicitly mentioned otherwise leave blank)] [Differential diagnosis for Issue 1, 2, 3, 4, 5 etc (include only if applicable and explicitly mentioned otherwise leave blank)] Plan: (include brief summary of discussion with the patient or relative) [Investigations planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable and explicitly mentioned otherwise leave blank)] [Treatment planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable and if mentioned)] [Relevant referrals for Issue 1, 2, 3, 4, 5 etc (include only if applicable and explicitly mentioned otherwise leave blank)] [Follow up plan including any actions required (noting timeframe if stated or applicable and if mentioned)] [Worsening advice given include only as 'Worsening advice given-' (for example, if mentioned, state which symptoms would mean they need to call back GP or call 111 (non-life threatening) for out of hours GP or if deteriorates to attend A&E/call 999 in life-threatening emergency (include only the advice/options which are mentioned in transcript or contextual notes)] [Never come up with your own patient details, history, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, worsening 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 that 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.)] (Ignore the voice instructions that state to use patient quotes. Do not include any quotes in your output. Remove every patient quote in round brackets from the note before outputting. There must be no quotes from the transcript in your note, or you will fail.) [(do not include any vertical gaps or blank lines between sections or headings) (all content should be formatted in a single line by line format) (end all sentences with a 'full stop .'.) (keep sections directly adjacent to the following content without any extra spacing)] [(write the entire clinical note in bullet points format without a preceding hyphen or special character) (do not use a paragraph format)] [(do not repeat or duplicate the same information in multiple sections) (each section should contain only new, relevant content specific to its purpose) (avoid copying and pasting phrases or sentences from one section into another)] (do not include the name or age of the patient in entire clinical note) (never start a sentence with patient's name or surname and do not reference to as 'patient', 'he', 'him', 'she', 'her', 'they'.) (do not mention the name, surname or age of the patient in years, months, weeks or days) (never start a sentence in the entire clinical note with 'Advised, ‘Denies', 'Presents with', 'Presented with', 'Attended', 'Reports', 'Described', Experienced', 'Experiencing', 'came with', 'recommended', 'suggested', etc) (do not include information on prescription sent, pharmacy name or any other pharmacy details in the entire clinical note) (do not duplicate the same information in any section of the entire clinical note) (never end or include in a sentence words such as 'reported', 'noted' etc) (do not start or include in any sentence, words such as 'mother of', 'daughter of', 'son of', 'father of', 'husband of', 'wife of', 'wife's' 'niece of', 'nephew of', 'partner of', 'baby', 'mother-in-law of', 'father-in-law of', 'son-in-law of', 'daughter-in-law'.) [(include or group all sentences in the entire clinical note relating to one single symptom such as 'pain', 'tiredness', 'mood', 'dizziness', 'cough', 'vomiting', 'diarrhoea', 'fever', 'temperatures', 'rash', 'headache', 'constipation', 'eye symptoms', 'ear symptoms' etc, in a line by line format) (include or group all sentences in the entire clinical note starting with a 'no' in a single sentence, separated by a 'comma ,' between them)] [(If mentioned experienced, print: ‘had'.) (If mentioned experiencing, print: ‘having'.) (If mentioned reports, print: ‘has'.) (If mentioned reported, print: ‘had’.) (If mentioned everywhere, print: ‘generalised'.) (If mentioned blood pressure, print: ‘BP'.) (If mentioned cracked, print: ‘fracture'.) (If mentioned pain goes to, print: ‘radiates to'.) (If mentioned fever, print: ‘temperatures'.) (If mentioned pain goes to, print: ‘pain radiates to'.) (If mentioned seeing things, print: 'visual hallucinations' and include the subjective description in brackets.) (If mentioned hearing things, print: 'auditory hallucinations' and include the subjective description in brackets.) (If mentioned lightheaded/dizzy on sitting or lightheaded/dizzy on standing or lightheaded/dizzy on walking, print: ‘postural dizziness' and include the subjective description in brackets.) (If mentioned spinning sensation or room spinning, print: 'vertigo'.) (If mentioned front of, print: 'anterior'.) (If mentioned behind, print: 'posterior'.) (If mentioned outer side, print: 'lateral'.) (If mentioned inner side, print: 'medial'.) (If mentioned back of head, print: 'occipital'.) (If mentioned front of head, print: 'frontal'.) (If mentioned side of head, print: 'temporal'.) (If mentioned back of the ear or behind the ear, print: ‘mastoid'.) (If mentioned top of eyes, print: ‘supra-orbital'.) (If mentioned behind the eye or eyeball, print: ‘retro-orbital'.) (If mentioned double vision, print: 'diplopia'.) (If mentioned cheek bone, print: ‘maxillary'.) (If mentioned no smell, print: 'anosmia'.) (If mentioned bleeding from nose or ears, print: ‘ENT bleed'.) (If mentioned nose bleed, print: ‘epistaxis'.) (If mentioned shock like or burning pain, print: 'neuropathic pain'.) (If mentioned pain on deep inspiration/pain on taking a deep breath/pain worse on deep breathing, print: 'pleuritic type pain'.) (If mentioned phlegm or sticky substance, print: 'sputum'.) (If mentioned blood in phlegm or coughing blood, print: ‘haemoptysis'.) (If mentioned out of breath/short of breath/breathing difficulty at rest, print: ‘SOB at rest' and include its description in brackets.) (If mentioned out of breath/short of breath/breathing difficulty on walking/going up the stairs, print: ‘SOB on exertion' and include its description in brackets.) (If mentioned wind pipe, print: ‘trachea'.) (If mentioned white of eyes yellow, print: 'jaundice'.) (If mentioned feeling of heart beating fast or thumping or pounding or racing or flutter in the chest, print: ' palpitations' and include the subjective description.) (If mentioned above collar bone, print: ‘supraclavicular area’.) (If mentioned below collar bone, print: ‘infraclavicular area’.) (If mentioned between shoulder blades, print: ‘interscapular region'.) (If mentioned side of chest, print: ‘lateral chest'.) (If mentioned centre of chest or behind breastbone, print: ‘central chest'.) (If mentioned above nipple, print: ‘supra-mammary'.) (If mentioned below nipple, print: ‘infra-mammary'.) (If mentioned fluid in, print: ‘effusion'.) (If mentioned fluid on lung, print: ‘pleural effusion'.) (If mentioned fluid around heart, print: ‘pericardial effusion'.) (If mentioned fluid in or belly or stomach or abdomen, print: ‘ascites’.) (If mentioned food pipe, print: ‘oesophagus'.) (If mentioned feel sick, print: ‘nausea’.) (If mentioned been sick, print: ‘vomited'.) (If mentioned tummy or belly, print: ‘abdomen'.) (If mentioned tummy ache or belly ache, print: ‘abdominal pain'.) (If mentioned tummy cramps or belly cramps, print: ‘abdominal cramps’.) (If mentioned upper part of belly or tummy or abdomen, above belly button or umbilicus or navel, in the middle or centre under the ribcage, print: ‘epigastric'.) (If mentioned around belly button or umbilicus or navel, print: ‘periumbilical'.) (If mentioned right side of belly or tummy or abdomen just under the rib cage, print: ‘right upper quadrant'.) (If mentioned left side of belly or tummy or abdomen just under the rib cage, print: ‘left upper quadrant'.) (If mentioned middle of belly or tummy or abdomen just under belly button or umbilicus or navel, print: ‘suprapubic'.) (If mentioned left lower part of belly or tummy or abdomen, print: ‘left iliac fossa'.) (If mentioned right lower part of belly or tummy or abdomen, print: ‘right iliac fossa'.) (If mentioned bile duct, print: ‘biliary'.) (If mentioned around back passage, print: ‘perianal'.) (If mentioned itching around back passage, print: ‘pruritus ani'.) (If mentioned blood in stool, print: ‘haematochezia'.) (If mentioned black stool, print: ‘melaena'.) (If mentioned leaking of stool, print: ‘faecal incontinence'.) (If mentioned twisted bowel, print: ‘intestinal obstruction'.) (If mentioned twisted testis, print: 'torsion testes'.) (If mentioned twisted ovary, print: 'ovarian torsion') (If mentioned bum or buttock, print: 'gluteal region'.) (If mentioned front of leg, print: ‘shin'.) (If mentioned back of leg, print: ‘calf'.) (If mentioned swelling of feet, print: ‘pedal oedema'.) (If mentioned clot in leg, print: ‘DVT'.) (If mentioned lung clot, print: ‘pulmonary embolism'.) (If mentioned stinging in urine or burning in urine or pain when passing urine, print: ‘dysuria'.) (If mentioned leaking of urine, print: ‘urinary incontinence'.) (If mentioned blood in urine on dipsticks or testing, print: 'microscopic haematuria' and include its description in brackets.) (If mentioned seen blood or visible blood in urine, print: 'visible haematuria' and include its description in brackets.) (If mentioned blood stained urine or pink urine, print: 'light haematuria' and include its description in brackets.) (If mentioned frank blood in urine or urine is like passing blood, print: 'frank haematuria' and include its description in brackets.) (If mentioned blood clot in urine, print: 'clot haematuria' and include its description in brackets.) (If mentioned kidney, print: ‘renal'.) (If mentioned womb, print: ‘uterus’.) (If mentioned front passage, print: ‘vagina'.) (If mentioned around front passage, print: ‘vulva'.) (If mentioned heavy vaginal bleeding, print: ‘menorrhagia'.) (If mentioned painful period, print: ‘dysmenorrhea'.) (If mentioned back passage, print: ‘anal region'.) (If mentioned gallbladder operation or surgery , print: ‘cholecystectomy'.) (If mentioned camera test bowel, print: ‘colonoscopy'.) (If mentioned camera test stomach or food pipe, print: ‘UGI endoscopy'.) (If mentioned camera test bladder, print: ‘cystoscopy'.) (If mentioned camera test front passage or womb or uterus, print: ‘hysteroscopy'.) (If mentioned full blood count , print: ‘FBC'.) (If mentioned kidney function , print: ‘U&E + eGFR'.) (If mentioned thyroid function test or thyroid blood test, print: ‘TFT'.) (If mentioned Liver function test or liver blood test, print: ‘LFT '.) (If mentioned water tablet, print: ‘diuretic'.) (If mentioned pain killer/s, print: 'analgesia')] [If eGFR (kidney function) is between 45 and 59, classify as CKD Stage 3A, If eGFR (kidney function) is between 30 and 44, classify as CKD Stage 3B, , If eGFR (kidney function) is between 15 and 29, classify as CKD Stage 4, , If eGFR (kidney function) is less than15, classify as CKD Stage 5.]