Scribe BC - Issues List
**Date admitted to ICU**: 28 October 2024
**ICU day**: 4
**Past Medical History**:
- Hypertension
- Type 2 Diabetes Mellitus
- Previous Myocardial Infarction
**Current Medications**:
- Metoprolol 50mg daily
- Lisinopril 10mg daily
- Insulin glargine 20 units at night
**Procedures**:
- Central line insertion
- Mechanical ventilation
1. Issue, problem or request 1 (include issue, request or condition name only)
- Acute Respiratory Distress Syndrome (ARDS)
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1 (include only if applicable)]
- Patient admitted with severe dyspnea and hypoxemia. Chest X-ray showed bilateral infiltrates.
- [Past medical history, previous surgeries, medications, relevant to issue 1 (include only if applicable)]
- PMH significant for hypertension and type 2 diabetes. Current medications include metoprolol, lisinopril, and insulin glargine.
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 1 (include only if applicable)]
- Vitals: BP 160/90, HR 110, RR 30, SpO2 88% on room air. Physical exam revealed bilateral crackles. Patient is intubated and on mechanical ventilation.
- [Likely diagnosis for Issue 1 (condition name only)]
- ARDS
- [Differential diagnosis for Issue 1 (include only if applicable)]
- Pneumonia, cardiogenic pulmonary edema
- [Investigations planned for Issue 1 (include only if applicable)]
- Arterial blood gas, chest CT scan
- [Treatment planned for Issue 1 (include only if applicable)]
- Mechanical ventilation with lung protective strategies, prone positioning, fluid management.
- [Relevant referrals for Issue 1 (include only if applicable)]
- None
2. Issue, problem or request 2 (include issue, request or condition name only)
- Septic Shock
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2 (include only if applicable)]
- Patient developed fever and hypotension.
- [Past medical history, previous surgeries, medications, relevant to issue 2 (include only if applicable)]
- No relevant past medical history.
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 2 (include only if applicable)]
- Vitals: BP 70/40, HR 130, Temp 39.5°C. Physical exam revealed warm extremities and altered mental status.
- [Likely diagnosis for Issue 2 (condition name only)]
- Septic Shock
- [Differential diagnosis for Issue 2 (include only if applicable)]
- Cardiogenic shock, hypovolemic shock
- [Investigations planned for Issue 2 (include only if applicable)]
- Blood cultures, lactate level, complete blood count
- [Treatment planned for Issue 2 (include only if applicable)]
- Fluid resuscitation, vasopressors, antibiotics.
- [Relevant referrals for Issue 2 (include only if applicable)]
- None
3. Issue, problem or request 3, 4, 5 etc (include issue, request or condition name only)
- Acute Kidney Injury
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc (include only if applicable)]
- Patient's creatinine has increased significantly.
- [Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc (include only if applicable)]
- No relevant past medical history.
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc (include only if applicable)]
- Urine output decreased. Creatinine 3.5 mg/dL.
- [Likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
- Acute Kidney Injury
- [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable)]
- Pre-renal, intrinsic, post-renal causes
- [Investigations planned for Issue 3, 4, 5 etc (include only if applicable)]
- Renal ultrasound, urine analysis
- [Treatment planned for Issue 3, 4, 5 etc (include only if applicable)]
- Fluid management, consider renal replacement therapy.
- [Relevant referrals for Issue 3, 4, 5 etc (include only if applicable)]
- Nephrology consult
**Critical Care**:
- Patient is currently intubated and mechanically ventilated for ARDS. Receiving vasopressors for septic shock. Monitoring urine output and renal function closely. Plan to wean sedation and assess neurological status daily.
"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."
Scribe BC - Issues List
**Date admitted to ICU**: [date admitted to icu] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
**ICU day**: [icu day #] (counted from date admitted to icu as day 1) (Only include if explicitly mentioned in transcript or context, else omit section entirely)
**Past Medical History**:
[relevant past medical history and chronic conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
**Current Medications**:
[list of current medications and doses] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
**Procedures**:
[list of procedures performed or planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
[1. Issue, problem or request 1 (include issue, request or condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Past medical history, previous surgeries, medications, relevant to issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Likely diagnosis for Issue 1 (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Differential diagnosis for Issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Investigations planned for Issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Treatment planned for Issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Relevant referrals for Issue 1 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
[2. Issue, problem or request 2 (include issue, request or condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Past medical history, previous surgeries, medications, relevant to issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Differential diagnosis for Issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Investigations planned for Issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Treatment planned for Issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Relevant referrals for Issue 2 (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
[3. Issue, problem or request 3, 4, 5 etc (include issue, request or condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Investigations planned for Issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Treatment planned for Issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
- [Relevant referrals for Issue 3, 4, 5 etc (include only if applicable)] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
(Keep in mind that the transcript may be about a variety of topics, from medical conditions, to mental health and social concerns, to dietary and exercise discussions and you must always attempt to use the transcript to create an list of topics discussed using the template above. Use as many bullet points as necessary to ensure clinical information is adequately spaced for easy reading comprehension.)
**Critical Care**: [critical care specific assessments and plans] (Only include if explicitly mentioned in transcript or context, else omit section entirely)
"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."
(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.)
