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General Practitioner Template

RC Year In Review Note Prior to Document

A professional General Practitioner template for healthcare professionals.
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Need to create a comprehensive annual review for your patients? The "RC Year In Review Note" template is designed for General Practitioners to summarise a patient's health journey over the past year. This template helps you document goals, significant events, progress, and any barriers encountered. It also includes sections for objective data, assessment, and a detailed plan. The template also includes a yearly marker table to track key health metrics. This template is perfect for creating detailed and insightful patient summaries, and is easily used with Heidi, the AI medical scribe, to generate these notes quickly and accurately.

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Goals: You aimed to improve your overall health and fitness, focusing on reducing visceral fat and enhancing your VO₂max. Summary of Events: Over the past year, you underwent several health assessments, including blood tests and a DEXA scan. You consulted with a nutritionist and started a new exercise regime. You were diagnosed with pre-diabetes and started taking Metformin. You also experienced a bout of the flu in January. Progress: You have seen improvements in several areas. Your visceral fat decreased by 10% between March and October. Your VO₂max increased from 38 to 42 ml/min/kg. Your fasting insulin decreased from 16 to 12 μIU/mL between July and December. You have also reported feeling more energetic. Barriers: Work-related stress and frequent travel in the first half of the year made it difficult to adhere to your diet and exercise plan. You also experienced a bout of the flu in January, which set you back. You found it challenging to maintain consistency with your medication. Objective Data: - 05/01/2024: Fasting glucose – 6.2 mmol/L (reference range: 4.0-5.6 mmol/L) - 10/10/2024: DEXA scan – Visceral fat: 1.2 kg (decreased from 1.5 kg in March) Assessment & Plan: 1. Pre-diabetes - Assessment: Your fasting glucose and HbA1c levels indicate pre-diabetes. Lifestyle modifications and medication are recommended. - Investigations or follow-up planned: Repeat HbA1c in 3 months. - Treatments or interventions recommended: Continue Metformin 500mg daily. Follow a low-carbohydrate diet. Increase physical activity to 150 minutes of moderate-intensity exercise per week. - Referrals if applicable: Referral to a diabetes nurse educator. 2. Elevated LDL Cholesterol - Assessment: Your LDL cholesterol is slightly elevated. - Investigations or follow-up planned: Repeat lipid panel in 6 months. - Treatments or interventions recommended: Increase soluble fibre intake. Consider starting a statin if LDL remains elevated. - Referrals if applicable: Referral to a dietician. ## Yearly Marker Table (12-month view) | Marker | Best | Start of Year | Most Recent | |----------------------------------|------------------------------|-------------------------------|------------------------------| | Total Cholesterol (mmol/L) | 4.5 mmol/L — 01/10/2024 | 5.2 mmol/L — 01/01/2024 | 4.8 mmol/L — 01/11/2024 | | LDL Cholesterol (mmol/L) | 2.8 mmol/L — 01/10/2024 | 3.5 mmol/L — 01/01/2024 | 3.1 mmol/L — 01/11/2024 | | ApoB (g/L) | 0.8 g/L — 01/10/2024 | 1.0 g/L — 01/01/2024 | 0.9 g/L — 01/11/2024 | | Lp(a) (nmol/L) | 150 nmol/L — 01/10/2024 | 160 nmol/L — 01/01/2024 | 155 nmol/L — 01/11/2024 | | Homocysteine (µmol/L) | 10 µmol/L — 01/10/2024 | 12 µmol/L — 01/01/2024 | 11 µmol/L — 01/11/2024 | | Omega-6/-3 ratio | 3.5 — 01/10/2024 | 4.0 — 01/01/2024 | 3.8 — 01/11/2024 | | Triglycerides (mmol/L) | 1.0 mmol/L — 01/10/2024 | 1.5 mmol/L — 01/01/2024 | 1.2 mmol/L — 01/11/2024 | | hsCRP (mg/L) | 1.0 mg/L — 01/10/2024 | 2.0 mg/L — 01/01/2024 | 1.5 mg/L — 01/11/2024 | | VO₂max (ml/min/kg) | 42 ml/min/kg — 01/10/2024 | 38 ml/min/kg — 01/01/2024 | 40 ml/min/kg — 01/11/2024 | | Fractional utilisation (%) | 75% — 01/10/2024 | 70% — 01/01/2024 | 72% — 01/11/2024 | | Fasting glucose (mmol/L) | 5.0 mmol/L — 01/10/2024 | 6.2 mmol/L — 01/01/2024 | 5.8 mmol/L — 01/11/2024 | | Fasting insulin (µIU/mL) | 12 µIU/mL — 01/10/2024 | 16 µIU/mL — 01/01/2024 | 14 µIU/mL — 01/11/2024 | | HbA1c (mmol/mol) | 40 mmol/mol — 01/10/2024 | 45 mmol/mol — 01/01/2024 | 43 mmol/mol — 01/11/2024 | | C-peptide (ng/mL) | 1.0 ng/mL — 01/10/2024 | 1.2 ng/mL — 01/01/2024 | 1.1 ng/mL — 01/11/2024 | | ALT (IU/L) | 20 IU/L — 01/10/2024 | 25 IU/L — 01/01/2024 | 22 IU/L — 01/11/2024 | | AST (IU/L) | 22 IU/L — 01/10/2024 | 28 IU/L — 01/01/2024 | 25 IU/L — 01/11/2024 | | Vitamin D (nmol/L) | 70 nmol/L — 01/10/2024 | 60 nmol/L — 01/01/2024 | 65 nmol/L — 01/11/2024 | | Ferritin (µg/L) | 100 µg/L — 01/10/2024 | 120 µg/L — 01/01/2024 | 110 µg/L — 01/11/2024 | | Weight (kg) | 75 kg — 01/10/2024 | 80 kg — 01/01/2024 | 77 kg — 01/11/2024 | | Fat mass (%) | 25% — 01/10/2024 | 30% — 01/01/2024 | 27% — 01/11/2024 | | ALMI (kg/m²) | 18 kg/m² — 01/10/2024 | 17 kg/m² — 01/01/2024 | 17.5 kg/m² — 01/11/2024 |
(Always use second-person voice — e.g., “You achieved…” Use full sentences in all narrative sections (Goals, Summary of Events, Progress, Barriers). Use bullet points only for Objective Data and Assessment & Plan. Use DD/MM/YYYY date format. Never invent data or include details not stated in the transcript. If a section has no relevant content, leave it blank — do not insert placeholders or generic text.) Goals: [Summarise your primary health and performance goals for the year using full sentences. Include specific objectives such as improving cognition, building muscle mass, reducing visceral fat, improving VO₂max, or stabilising blood sugar.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary of Events: [Provide a narrative timeline of major health events, investigations, interventions, and context over the past year. Include assessments (e.g., MRI, Fibroscan, CPET), consultations, new diagnoses, medications, or life stressors. Use at least 4–6 full sentences.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Progress: [Describe specific improvements over the year across multiple domains — symptoms, biomarkers, body composition, fitness, mental clarity, recovery, adherence. Use quantitative data and dates where possible (e.g., “Your fasting insulin decreased from 16 to 12 μIU/mL between July and December”). Target 4–6 sentences.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Barriers: [Describe personal, behavioural, medical, or environmental challenges that interfered with your goals. Mention work stress, travel, illness, injuries, compliance issues, or sleep disruption. Reference timing and impact. Target 4–6 sentences.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective Data: - [DD/MM/YYYY: Test name – result with units and reference range] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Summarise tracked data (e.g., Oura, CGM) or physical exam findings if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment & Plan: 1. [Condition/Issue Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Assessment or clinical summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Investigations or follow-up planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Treatments or interventions recommended] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Referrals if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [Next condition/issue...] (Repeat structure as above, only if explicitly mentioned.) 3. [Add additional conditions/domains as needed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ## Yearly Marker Table (12-month view) (Use the entire record and the attached biomarker PDF in the Context tab. Populate ONLY the markers listed below. For each cell, output: value + standard unit + date in DD/MM/YYYY → e.g., `4.2 mmol/L — 03/06/2025`. Do NOT include reference ranges in this table (use them in the narrative sections above). If a marker is absent, write **_NOT MENTIONED_**.) | Marker | Best | Start of Year | Most Recent | |----------------------------------|------------------------------|-------------------------------|------------------------------| | Total Cholesterol (mmol/L) | [ ] | [ ] | [ ] | | LDL Cholesterol (mmol/L) | [ ] | [ ] | [ ] | | ApoB (g/L) | [ ] | [ ] | [ ] | | Lp(a) (nmol/L) | [ ] | [ ] | [ ] | | Homocysteine (µmol/L) | [ ] | [ ] | [ ] | | Omega-6/-3 ratio | [ ] | [ ] | [ ] | | Triglycerides (mmol/L) | [ ] | [ ] | [ ] | | hsCRP (mg/L) | [ ] | [ ] | [ ] | | VO₂max (ml/min/kg) | [ ] | [ ] | [ ] | | Fractional utilisation (%) | [ ] | [ ] | [ ] | | Fasting glucose (mmol/L) | [ ] | [ ] | [ ] | | Fasting insulin (µIU/mL) | [ ] | [ ] | [ ] | | HbA1c (mmol/mol) | [ ] | [ ] | [ ] | | C-peptide (ng/mL) | [ ] | [ ] | [ ] | | ALT (IU/L) | [ ] | [ ] | [ ] | | AST (IU/L) | [ ] | [ ] | [ ] | | Vitamin D (nmol/L) | [ ] | [ ] | [ ] | | Ferritin (µg/L) | [ ] | [ ] | [ ] | | Weight (kg) | [ ] | [ ] | [ ] | | Fat mass (%) | [ ] | [ ] | [ ] | | ALMI (kg/m²) | [ ] | [ ] | [ ] | (Never come up with your own patient details, assessment, plan, interventions, evaluation, markers, or next steps — use only the transcript, contextual notes, or clinical note as reference. If any information is missing, leave it blank or mark as **_NOT MENTIONED_** in the table.)
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Specialty

General Practitioner

Used

1 times

Type

Note

Last edited

25.8.2025

Created by

Anonymous

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