Netcare Consult

[Patient name] and [the parent present, mother or father] gave me verbal consent to use AI transcription today: ID: [age in years if older than 2 years old or in months if younger] [sex], referred for [referral reason], here with [which parent] today, HPI: [mention details around the referral problem] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Systems: [mention if not related to referring problem: nutrition, bladder & bowel function, sleep, screen time, headaches, vision or hearing concerns, chest pain, palpitations, breathing problems, abdominal pain, joint pains or swellings, rashes. Only mention if discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PMHx: [review pregnancy, labor & delivery details, admissions, surgeries or any specific past medical problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DEVT/SCHOOL: [review speech, gross motor skills, fine motor skills and social skills, if mentioned] [document grade level, if in any special programs or extra support or any concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDS: [prescribed medications or supplements or vitamins] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES: [any confirmed allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) IMMUNIZATIONS: [document if up to date and their last vaccines] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FHx: [document any medical history in the family or negative history if discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SHx: [document who the patient lives with, parent occupation or if there any financial concerns in the family] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) O/E: Well, active, mmm -PERL, EOM normal -ENT normal, no nodes, neck supple, no palpable thyroid -Chest clear, good AE, no distress, RR -HS & pulses normal, BP, HR -Abdo-soft, no masses/HSM, nontender, BS present -GU-normal [male or female] -MSK-normal hips [for infants], normal gait [if walking], normal spine -CNS-face symmetrical, normal tone & equal power all limbs, DTRs symmetrical, toes downgoing -Skin clear ASSESSMENT [make a detailed summary statement in prose in a paragraph] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PLAN [list the plan for the patient, label 1, 2, 3, etc] (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.)