Travel Health Consultation:
Destination: [list the destinations the patient will be visiting]
Duration: [how long are they going to be away for]
Departure: [what day will the patient be leaving on]
Plans during trip:
- [describe reason for travel consultation, including destination and duration of travel] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Summary of Recommendations:
- [mention recommended vaccinations for travel destinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention non-vaccine recommendations provided for travel destinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Comprehensive Travel Consultation Notes:
Past Medical History:
- [list any chronic medical conditions]
Past Vaccination History:
- [list previous vaccinations and dates] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any adverse reactions to previous vaccinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Risk Assessments:
COVID and Influenza:
- [describe the advice provided by the doctor to the patient for COVID vaccination during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether the patient was eligible for a COVID vaccination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether the patient accepted or refused the recommendation for a COVID vaccination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe the advice provided by the doctor to the patient for influenza or flu vaccination during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether the patient was eligible and suitable for an influenza or flu vaccination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether the patient accepted or refused the recommendation for an influenza or flu vaccination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Hepatitis A:
- [provide brief details of Hepatitis A risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Hepatitis A during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Hepatitis A vaccination was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Hepatitis A is not discussed during the consult then delete the heading "Hepatitis A:" and leave this section blank)
Typhoid Fever:
- [provide brief details of Typhoid Fever risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Typhoid Fever during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Typhoid Fever vaccination was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Typhoid Fever is not discussed during the consult then delete the heading "Typhoid Fever:" and leave this section blank)
Gastroenteritis:
- [provide brief details of Gastroenteritis risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Traveller's Diarrhoea or Gastroenteritis during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [provide advice around safe food and water consumption specific to the destination(s) of travel identified in the consult]
- [document whether or not the patient agreed to take a "Gastrokit" with them]
(If Gastroenteritis is not discussed during the consult then delete the heading "Gastroenteritis:" and leave this section blank)
Dengue Fever and Other Mosquito Borne Illnesses:
- [provide brief details of the Mosquito Borne Illnesses that are endemic to the specific destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Typhoid Fever during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Mosquito Borne Illnesses were not discussed during the consult then delete the heading " Dengue Fever and Other Mosquito Borne Illnesses:" and leave this section blank)
Malaria:
- [provide brief details of Malaria risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Malaria during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Malaria Chemoprophylaxis was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [If Chemoprophylaxis was recommended for this trip, identify the specific product recommended and quantity of tablets provided as well as any other instructions provided relating to that product/medication] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Malaria is not discussed during the consult then delete the heading "Malaria:" and leave this section blank)
Japanese Encephalitis:
- [provide brief details of Japanese Encephalitis risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Japanese Encephalitis during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Japanese Encephalitis vaccination was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Japanese Encephalitis is not discussed during the consult then delete the heading "Japanese Encephalitis:" and leave this section blank)
Rabies:
- [describe in detail the advice provided to the patient around rabies]
- [note if rabies vaccination was recommended for this trip]
- [note if the patient refused rabies vaccination despite the doctor recommending it]
- [mention post-exposure prophylaxis advice for rabies prone wounds based]
Yellow Fever:
- [provide brief details of Yellow Fever risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Yellow Fever during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Yellow Fever vaccination was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- "Explained that Yellow Fever Vaccine (Stamaril) is a live vaccine and confirmed that the patient does not have any immune compromising conditions or contraindications to having live vaccines."
- [If the patient is >65 years old include the following comments "Yellow Fever Vaccine-Associated Neurotropic Disease (YEL-AND) and Yellow Fever Vaccine-Associated Viscerotropic Disease (YEL-AVD) are rare but significant risks in people over 65 and as such we have agreed not to vaccinate, a valid Yellow Fever Waiver Certificate has been provided for the destination and duration of this trip."
(If Yellow Fever is not discussed during the consult then delete the heading "Yellow Fever:" and leave this section blank)
MPox:
- [provide brief details of Mpox or Monkey Pox risk specific to the destination(s) of travel identified in the consult]
- [describe the advice provided by the doctor to the patient for Mpox or Monkey Pox during the consult] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [State whether Mpox or Monkey Pox vaccination was recommended or not required for this trip] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(If Mpox or Monkey Pox is not discussed during the consult then delete the heading "MPox:" and leave this section blank)
Tick Borne Encephalitis:
- [If tick borne encephalitis is discussed and recommended during the consult, include the following statement " - Tick-borne encephalitis (TBE) is a viral infection affecting the central nervous system - it is caused by three different virus sub-types: European, Far eastern and Siberian and is endemic in many regions of Eurasia
- Ticks are commonly found low in the undergrowth
- Incubation period for this mode of transmission ranges from 7 - 28 days
- Infection can also be acquired by consuming unpasteurised dairy products from infected cows, goats or sheep - four days is the average incubation period in these cases
- European (endemic in mainland Europe); Far eastern (eastern Russia and in forested regions of China and Japan); and Siberian (the rest of Russia, Siberia, Urals region and in some areas of north-eastern Europe)
- Vaccination: Inactivated viral vaccine
- Schedule: Day 0, 1 - 3 months, 5 - 12 months after the second dose (If no ongoing risk of exposure 3rd dose may not be required)
- Efficacy: over 90% after the second vaccination and above 97% after the 3-dose primary series
- Boosters: First booster after 3 years, then at 5-year intervals if at risk - every 3 years for people over 60 years.
- Side Effects: Mostly mild and transient
Swelling, redness and pain at the injection site, headache, fatigue, malaise, nausea, muscle pain
- Recommendation: Based on itinerary and nature of travel I have recommended the TicVac vaccine
- Explained to patient that due to the cost and need for us to order the vaccines, they must pay for the 2 primary doses in advance today and we will notfity when they are available
- SAS Application to be done upon supply, via the SAS portal using Category C (M89) indication pathway for which prior approval is not required copy of receipt to be added to file once received."]
Vaccinations were administered by the practice nurse with thanks
Patient was asked to stay in the practice for 15 minutes post vaccination to ensure no immediate hypersensitivity reactions occurred.
(make all headings bold text formatted)
Note created with the assistance but not reliance on Scribing software "s10.ai" by s10.ai
- patient verbally consent obtained prior to activation of transcription
- no audio recordings obtained or retained with either s10.ai or in our system
- In s10.ai patient info is de-identified and encounter is labelled with first last name initial only for future reference.
- All transcription records are deleted after 48 hours by default setting
All vaccine costs discussed with patient during consult and a copy of the vaccine costs schedule including dose regime was provided for their reference during the consult.
(Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)