Consulting Assessment:
Patient Information:
- John Smith
- 12/03/1950
- 12 Acacia Avenue, Sydney NSW, 2000 (Resident for 20 years in this address and in NSW)
- 1234567
- Present for consultation: Wife, Mary Smith
Consultation Details:
- 1 November 2024
- Consulting clinician name and title: Dr. Jane Doe, General Practitioner
- Referring clinician name and title: Dr. Robert Green, Oncologist
Reason for Consultation:
- Request for Voluntary Assisted Dying (VAD) assessment.
- Diagnosis: Stage IV metastatic lung cancer with a poor prognosis. Prognosis is estimated to be 2-3 months.
Medical History:
- Past medical history: Hypertension, COPD, previous myocardial infarction.
- Previous surgeries: Coronary artery bypass graft (2010), Right upper lobectomy (2022).
- Current medications: Ramipril 5mg daily, Salbutamol inhaler as needed, Morphine Sulphate 10mg every 4 hours.
- Allergies: Penicillin.
Social History:
- Smoker for 40 years, quit 2 years ago. Lives with wife. Supportive family.
Family History:
- Father died of lung cancer at age 70. Mother has diabetes.
Medical Team
- Dr. Robert Green (Oncologist), Dr. Jane Doe (GP), Dr. Sarah Brown (Palliative Care Specialist).
Review of Systems and Symptoms:
- Patient reports severe shortness of breath, chronic pain (7/10), fatigue, and loss of independence. Patient is unable to perform activities of daily living.
Treatment Options:
- Patient has been receiving chemotherapy and radiation therapy, but the cancer has progressed. Palliative care is being provided to manage symptoms. Patient has been informed of the outcomes of the care and treatment.
VAD administration options:
- Method preference: Self-administered oral medication.
- Contact person: Mary Smith
- Administration will cause death
Competency
- Competent: Patient is oriented to time, place, and person. Demonstrates a clear understanding of the VAD process and the implications.
Elligibility:
- Elligible
- "I found John Smith's request enduring and no evidence that there has been any external pressure or duress placed to request VAD".
Recommendations:
- Proceed with the VAD process as per NSW legislation.
Follow-Up:
- Schedule a follow-up appointment to discuss the next steps and provide the necessary paperwork.
Consulting Assessment:
Patient Information:
- [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [patient date of birth] (only include patient date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
-[patient address, including length of residency at the address and in NSW](only include if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [patient medical record number] (only include patient medical record number if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [present for consultation] (only include names of others present if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Consultation Details:
- [date of consultation] (only include date of consultation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [consulting clinician name and title] (only include consulting clinician name and title if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [referring clinician name and title] (only include referring clinician name and title if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Reason for Consultation:
- [reason for consultation] (only include reason for consultation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- (summarise the diagnosis and prognosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History:
- [past medical history] (only include past medical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [previous surgeries] (only include previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [current medications] (only include current medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [allergies] (only include allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Social History:
- [social history] (only include social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Family History:
- [family history] (only include family history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical Team
- (only include list of doctors including GP and specialists involved in patients care if it has been mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Review of Systems and Symptoms:
- [review of systems and symptoms described by the patient including any distress including fatigue and loss of independence, pain] (only include review of systems if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Treatment Options:
- [treatment options] (only include treatment options including chemotherapy, surgery or palliative care and the outcomes of the care and treatment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
VAD administration options:
- [Method preference ] (self administered oral or practitioner administered, only include preference if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(if self administered preference, then a contact person must be appointed, name the contact person if mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
-[ Administration will cause death]
Competency
-[Competent] (mention if the patient found competent as they are orientated and demonstrate a good understanding of the topic and process,only include preference if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Elligibility:
- [Elligible] (mention if patient found elligible only include plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- "I found [patients name] request enduring and no evidence that there has been any external pressure or duress placed to request VAD".
Recommendations:
- [recommendations] (only include recommendations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Follow-Up:
- [follow-up instructions] (only include follow-up instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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.)
