This consultation was documented using ambient scribe technology. The note has been reviewed and approved by Dr. Eleanor Vance.
PRESENTING COMPLAINT:
Patient presents today with a three-day history of a sore throat and cough.
HISTORY:
The patient reports a gradual onset of symptoms, with increasing throat pain and a dry cough. No fever or chills reported. Denies any known allergies. No significant past medical history. Currently taking paracetamol for symptom relief.
ICE (Ideas, Concerns, Expectations):
Ideas: Patient believes they have a common cold.
Concerns: Worried about the cough developing into something more serious, like pneumonia.
Expectations: Hopes to receive advice on how to manage symptoms and rule out any serious underlying conditions.
RELEVANT NEGATIVES:
No chest pain, shortness of breath, or haemoptysis. No recent travel or contact with anyone with similar symptoms. No red flags for cancer.
EXAMINATION:
Throat examination revealed mild erythema. No tonsillar exudates. Chest auscultation clear. Temperature 37.2°C.
QUALITY INDICATORS (when relevant):
Non-smoker. Drinks alcohol occasionally, within recommended limits. BMI 24.
MANAGEMENT/PLAN:
Advised on symptomatic relief with paracetamol and rest.
Reassured regarding the self-limiting nature of the illness.
Provided information on cough etiquette and hand hygiene.
Advised to return if symptoms worsen, or if they develop any new symptoms such as difficulty breathing or chest pain.
PRESCRIPTIONS:
Paracetamol 500mg, one to two tablets every 4-6 hours as needed for pain, as needed, supply for 7 days.
INFORMATION & CONSENT:
Provided patient with a leaflet on managing coughs and colds. Discussed the benefits and risks of symptomatic treatment. Patient verbalised understanding and gave consent for the management plan.
SAFETY NETTING:
Advised to seek immediate medical attention if they develop difficulty breathing, chest pain, or start coughing up blood. Advised to contact the surgery if symptoms do not improve within a week.
FOLLOW-UP:
No follow-up required unless symptoms worsen or as per safety netting advice. Advised to contact the surgery if symptoms do not improve within a week.
["This consultation was documented using ambient scribe technology. The note has been reviewed and approved by [insert name of clinician]."]
PRESENTING COMPLAINT:
[Brief statement of why the patient attended the consultation, ensuring that multiple presenting complaints are kept separate unless they are clearly linked] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
HISTORY:
[Concise relevant history including duration, severity, associated symptoms, relevant past medical history, and current medications pertaining to the presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
ICE (Ideas, Concerns, Expectations):
[Document the patient's own understanding of their condition, what they are worried about, and what they hoped to achieve from the consultation, using the ICE format as separate lines] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
RELEVANT NEGATIVES:
[Document important symptoms checked and ruled out, including any red flags that were excluded. If cancer is a possibility, specifically reference any NG12 symptoms or signs that were present or absent] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
EXAMINATION:
[Clinical findings from the examination, or state "Not examined" if no examination was performed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
QUALITY INDICATORS (when relevant):
[Include details of smoking status, alcohol consumption, Body Mass Index (BMI), Blood pressure, or any other relevant quality/lifestyle indicators pertinent to the consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
MANAGEMENT/PLAN:
[Include details of advice given to the patient, investigations ordered, and any referrals made, use bullet points (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
PRESCRIPTIONS:
[List any medications prescribed in the format: Drug name, dose, frequency, duration, quantity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
INFORMATION & CONSENT:
[Document any information or leaflets given, discussions about treatment options, and shared decision-making processes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
SAFETY NETTING:
[Specific advice provided to the patient on symptoms to watch for and when/how to seek further help, including timeframes and contact methods] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
FOLLOW-UP:
[Clear arrangements for follow-up with specific timeframes] (Only include if explicitly mentioned in transcript, context 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 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.)