Scribe BC - Emerg Note Simple

Scribe BC - Emerg Note Simple **HISTORY OF PRESENTING ILLNESS** [Brief description of reason for emergency visit] (Only include reason for emergency visit if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Detail history of presenting illness including onset, duration, severity, associated symptoms] (Only include history of presenting illness if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Detail social history including smoking, alcohol, drug use, work/study, living situation, living conditions, social services, activities of daily living etc] (Only include social history if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) **RELEVANT PAST MEDICAL HISTORY** [Detail past medical history including chronic conditions, resolved conditions, previous surgeries using a list format] (Only include past medical history if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) **PHYSICAL EXAMINATION** [Vital signs and nursing assessment reference] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Include "Vitals: See nursing assessment" if referenced in transcript.) [General: General observations and exam findings] (Only include general exam findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [System-specific exam: findings from examination of CVS, Resp, Abdo, CNS, etc] (Group findings under system where possible. Only include system-specific findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **PROCEDURES** [Detail any procedures performed including procedure type, technique, complications, outcomes, and procedural notes] (Only include procedures if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **INVESTIGATIONS** [Include any mentioned lab investigations, diagnostic imaging results, ECG results, etc] (Only include blood test, diagnostic imaging findings, or ECG results if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **COURSE IN ED** [Detail the patient's course in the ED including medications with doses, procedures, treatments, consults, etc] (Only include the patient's course in the ED if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own course in ED.) **IMPRESSION AND PLAN** [Primary diagnosis] (Only include primary diagnosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own assessment or diagnoses.) [Differential diagnoses] (Only include differential diagnoses if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own differential diagnoses.) [Detail immediate management plans including medications with doses, procedures, treatments, etc] (Only include immediate management plans if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own immediate management plans.) [Referrals: Specialty consultations] (Only include referrals if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own referrals.) [Discharge Criteria: Conditions for discharge or admission] (Only include discharge criteria if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own plans.) [Follow-up: Instructions for follow-up care] (Only include follow-up care instructions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own follow-up instructions.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, 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 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.)