Bradford VTS GP concise consult

HISTORY - [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)(Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) PMH - [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints](Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) EXAMINATION - [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.) IMPRESSION 1. [list primary diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) 2. [list secondary diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) 3. [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) PLAN [1. Issue, problem or request 1 (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 1 (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Differential diagnosis for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Investigations planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Treatment planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Relevant referrals for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) [2. Issue, problem or request 2 (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 2 (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Differential diagnosis for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)](Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Investigations planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Treatment planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Relevant referrals for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) [3. Issue, problem or request 3, 4, 5 etc (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Differential diagnosis for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Investigations planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Treatment planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) - [Relevant referrals for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Instead of minutes, use the word mins, so instead of 3 minutes, write 3 mins. Instead of seconds, write secs. Instead of hours, use the letter h for example 3 hours should be written as 3h. Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches) (Never come up with your own 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.) **(Global Formatting Rules: **Always use **bullet-point lecture note style**. Do **not** write full sentences unless unavoidable.Use **short, contracted forms**: For example: “reports cough 2wks” instead of “patient says he has had a cough for 2 weeks”, “to continue meds” instead of “I advised patient to continue with medication”, “denies SOB, CP” instead of “Patient denies having shortness of breath or chest pain”. Use **abbreviations** where safe and standard e.g. SOB, CP, abdo, PMH, FH, SH. Keep each entry **as brief as possible without losing meaning**. Only use short narrative style for **patient’s Ideas, Concerns, Expectations (ICE)** where bullet points risk losing nuance. Never add your own interpretation, assumptions, or invented details. Only include what is **explicitly mentioned in transcript / clinical note / contextual notes**. If info is missing. leave blank - do not fill and do not assume) (Conciseness Examples. Example 1 – Symptom Reporting Before i.e. full sentence: “Patient says he has had a cough for the past two weeks which is worse at night.” After i.e. Concise version: reports cough 2wks, worse night Example 2 – Advice / Plan. Before i.e. full sentence: “I advised the patient to continue taking his current medication.” After i.e. Concise version: to continue meds Example 3 – Negatives / Denials. Before i.e. full sentence: “Patient denies experiencing shortness of breath or chest pain.” After i.e. Concise version: denies SOB, CP. Example 4 – Past Medical History. Before (full sentence): “Patient has a past medical history of asthma diagnosed in childhood and hypertension for the past 10 years.” After i.e. concise version: PMH: asthma (childhood), HTN 10y. Example 5 – Investigations. Before i.e. full sentence: “Blood test results show elevated cholesterol but normal liver and kidney function.” After i.e. concise version: blds: ↑chol, LFT/RFT normal. Example 6 – ICE = Ideas, Concerns, Expectations. Before i.e. full sentence: “The patient is worried that their persistent headache might be a brain tumour, and they would like a scan to rule this out.” After i.e. short narrative OK: Concern: worried headache = tumour. Expectation: wants scan to rule out) (Instead of days, use the letter d for example 5 day history of cough should be written as 5d h/o cough. for months use m e.g. 7 months weight loss should be weight loss for 7m. for years use y, so for 6 years history of headaches, write 6y h/o headaches)