Identification
Patient Name: Buddy (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Age: 8 years (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Gender: Male (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Mechanism of Injury / Illness
Incident Details: Buddy was hit by a car while running in the road. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Injury / Illness: Suspected fractured femur, multiple abrasions, and possible internal injuries. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Signs and Symptoms
Observations:
* Laboured breathing
* Pale mucous membranes
* Significant bleeding from a wound on the left hind leg
* Unresponsive to verbal stimuli
* Heart rate: 140 bpm
* Respiratory rate: 40 breaths/min (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Treatment
Interventions:
* Applied direct pressure to the bleeding wound.
* Administered oxygen via mask.
* Immobilised the left hind leg with a splint.
* Initiated IV fluids.
* Monitored vital signs. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Medications:
* Administered 0.02mg/kg of Buprenorphine IV for pain relief. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Response to Treatment:
* Breathing improved slightly.
* Heart rate decreased to 120 bpm.
* Patient remained unresponsive. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Allergies
Known Allergies: None known. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Medications
Current Medications: None. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Background
Medical History: Unknown. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Social History: Outdoor cat, allowed to roam freely. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Other Information
Next of Kin: Owner: Sarah Miller, Phone: 07700 900123 (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Handover Time: 10:45 (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(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 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.) (Use as many bullet points as needed to capture all the relevant information from the transcript.)
Identification
Patient Name: [full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Age: [age in years] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Gender: [gender] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Mechanism of Injury / Illness
Incident Details: [brief description of the incident or illness onset] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Injury / Illness: [specific injury or illness identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Signs and Symptoms
Observations: [vital signs and symptoms observed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Treatment
Interventions: [details of any treatment provided on-scene or en route] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Medications: [any medications administered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Response to Treatment: [patient’s response to interventions and medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Allergies
Known Allergies: [any known allergies, especially to medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Medications
Current Medications: [list of medications the patient is taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Background
Medical History: [relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Social History: [relevant social history factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Other Information
Next of Kin: [next of kin details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Handover Time: [time of handover to hospital staff] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(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 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.) (Use as many bullet points as needed to capture all the relevant information from the transcript.)