History and Examination - Family Medicine Australia

[medical student presence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If included, add: "Patient has given consent for medical student to be present at consultation today.") Patient given verbal consent for use of AI Scribe to assist with writing consultation notes. Quick Summary of below: Short summary of issues and current plan from this consult for each issue using dot points - this should be written in medical nomenclature and be brief. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) If results are discussed during the consult, they can be entered here. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History: History notes using ICD nomenclature. Number the issues as they come up. - These issues are to be the subjective information given by the patient. Under each issue, the information relevant to that issue should be listed in dot points. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) If results are discussed during the consult, they can be entered here. If results are added, a heading named "Results Discussed:" can be included. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: Examination findings noted during consultation. Keep blood pressure and vital signs at the top. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Impression: Write down the impression of what is going on - i.e., diagnoses or differential diagnoses. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: Write down plan for current treatment using medical nomenclature. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Create a simplified patient summary with current plan using non-medical language that anyone could understand. This plan should be in dot points. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)