Adrian M ED

[Date, month, year] (Only include if explicitly mentioned in transcript, context or clinical note. Format as day, month, year of the consultation.) [Time] (Only include if explicitly mentioned in transcript, context or clinical note. Format as hour:minutes in 24-hour format in Auckland time.) _Presenting complaint_ [Presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in one clear sentence.) _History of presenting complaint_ [Detail in chronological order. New line for each sentence with dash symbol.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use dash at start of each sentence.) [Any system findings relevant to the complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Integrate into above with dash.) Past medical history – [List each past medical history entry on a new line with dash] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medication and allergies – [List each current medication on a new line with dash] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) – _[Underline any known allergy]_ (Only include if explicitly mentioned in transcript, context or clinical note.) Social history [Document smoking, alcohol, drug use, occupation, ADLs, carer needs, and other relevant social details.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs.) Examination – [Airway findings if present] – [Breathing findings if present] – [Circulation findings if present] – [Neurological/Disability findings including GCS, pupils, limb power] – [Exposure/injury findings or other general observations] (Only include if explicitly mentioned in transcript, context or clinical note. Use dash at start of each new finding, preserve ABCDE sequence if mentioned.) Investigations – [List any investigations ordered or completed with date if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write each investigation on a new line with dash.) Impression [Document only if a diagnosis or impression is explicitly stated.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a short paragraph.) Clinical management – [List each management action such as prescriptions, referrals, education, follow-ups etc. Use new line and dash for each] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Consent [Verbal consent obtained from patient] (Only include if consent box has been received in transcript, context or clinical note, else omit statement.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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.)