**<u>Type 2 Diabetes Risk Evaluation - 40-49 yrs </u>**
Patient: Mrs. Sarah Jones
DOB: 12/03/1978
Date: 1 November 2024
Clinician: Dr. Emily Carter
**Eligibility:**
- Confirmed patient age is 46 years.
- AUSDRISK score of 18, indicating high risk.
- AUSDRISK completed on 20th October 2024.
- Confirmed no previous claim in the last 3 years.
- Documented that patient consents to diabetes risk assessment.
**History:**
- Relevant medical history includes high cholesterol and a family history of type 2 diabetes.
- Lifestyle factors include smoking (10 cigarettes per day), a diet high in processed foods, and limited physical activity (sedentary job). Alcohol consumption is moderate (2 glasses of wine per week).
- Family history of type 2 diabetes in mother and maternal grandmother.
**Examination:**
- BP: 140/90 mmHg, BMI: 31 kg/m².
**Investigations:**
- HbA1c ordered.
- Fasting glucose ordered.
- Lipid profile including HDL ordered.
**Interventions & Follow-up:**
- Advice given to address modifiable risk factors:
- Nutrition: Advised to follow a Mediterranean diet.
- Physical Activity: Recommended 30 minutes of moderate intensity activity 5 days/week.
- Smoking Cessation: Offered information on Quitline and discussed pharmacotherapy options.
- Weight Management: Discussed BMI and waist circumference targets.
- Referrals made or considered:
- Referral to a dietitian for dietary advice.
- Referral to Quitline for smoking cessation support.
- Follow-up planned in 3 months.
Billing & Claiming:
"Claimable once every 3 years."
**<u>Type 2 Diabetes Risk Evaluation - 40-49 yrs </u>**
Patient: [Patient name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
DOB: [Date of birth] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Date: [Date of consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Clinician: [Clinician name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Eligibility:**
- [Confirm patient age is 40–49 years] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point.)
- [AUSDRISK score and indication that score is high] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point.)
- [Date of AUSDRISK completion if within past 3 months] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point.)
- [Confirm no previous claim in the last 3 years] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point.)
- [Document that patient consents to diabetes risk assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point.)
**History:**
- [Relevant medical history, including high cholesterol, overweight, hypertension, impaired glucose metabolism] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
- [Lifestyle factors including smoking status, dietary patterns, physical activity, alcohol consumption] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
- [Family history of diabetes or other chronic diseases] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.)
**Examination:**
- [Details of physical examination performed including BP and BMI] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
**Investigations:**
- [Clinical investigations ordered (if indicated): HbA1c, fasting glucose, OGTT, ELFTs, lipid profile including HDL] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
**Interventions & Follow-up:**
- [Advice given to address modifiable risk factors such as nutrition, physical activity, smoking cessation, alcohol reduction, and weight management. Include smoking cessation support options such as Quitline, pharmacotherapy; dietary advice including Mediterranean or DASH diet; exercise advice such as 30 minutes of moderate intensity activity 5 days/week; alcohol guidelines as per national standards; weight goals including BMI and waist circumference targets.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
- [Referrals made or considered to dietitian, exercise physiologist, psychologist, Quitline, or lifestyle programs. Indicate if under GPMP or MHCP where applicable.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
- [Follow-up date or timeframe planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in sentence format.)
Billing & Claiming:
"Claimable once every 3 years."
(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 include 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 omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
