Date Of Procedure: [Document the date of the procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in format DD/MM/YYYY.)
Patient Name: [Record the full name of the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
DOB: [Document the patient's date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in format DD/MM/YYYY.)
Drs Name: [Record the name of the performing doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
GMC Number: [Document the GMC registration number of the performing doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medical History Reviewed: [Confirm if the patient's medical history was reviewed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Changes Documented: [Describe any changes noted in the patient's medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Consent Signed By Patient: [Confirm if the consent form was signed by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Consent Signed By Dr: [Confirm if the consent form was signed by the doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cost Agreed By Dr: [Confirm if the cost of the procedure was agreed upon by the doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cost Agreed By Patient: [Confirm if the cost of the procedure was agreed upon by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Photos Taken: [Confirm if photos were taken for documentation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Area Disinfected: [Describe the method or confirmation of area disinfection] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Dose: [Record the dosage of the injectable product used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Aftercare Given: [Detail the aftercare instructions provided to the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Presenting Complaint: [Document the patient's primary reason for seeking the procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Diagnosis: [Record the clinical diagnosis or assessment leading to the procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Do not infer or assume a diagnosis.)
Any Concerns/Reactions After Treatment: [Document any immediate concerns or reactions experienced by the patient post-treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Lot: [Record the lot number of the product used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Expiry: [Record the expiry date of the product used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in format DD/MM/YYYY.)
Dilution: [Record the dilution ratio or method if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Needle: [Document the type and size of the needle used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cannula: [Document the type and size of the cannula used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Expectations: [Document the patient's expectations from the procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Follow Up Plan: [Detail the planned follow-up schedule or instructions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Signed By Dr: [Confirm if the document was signed by the doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, or 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 that it has not been explicitly mentioned; simply omit the placeholder or leave it blank. Use as many lines, paragraphs or bullet points as needed to capture all relevant information.)