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Family Medicine Specialist Template

Multi-Issue Consultation Note

A professional Family Medicine Specialist template for healthcare professionals.
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About this template

This Multi-Issue Consultation Note template is an essential tool for any Family Medicine Specialist seeking to streamline their patient documentation. Designed to capture comprehensive details during consultations involving multiple patient concerns, it ensures no vital information is missed. Clinicians can easily document present complaints, relevant past medical history, examination findings, and a clear plan for each issue, making it an ideal 'medical progress note example'. Heidi, your AI medical scribe, intelligently populates this template from your consultation transcript, allowing for efficient, organised record-keeping. It's perfect for general practitioners managing complex patient presentations, offering a structured approach to clinical note-taking that supports thorough assessment and ongoing care.

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Family Medicine Specialist Note 45-year-old female seen with complaints of persistent fatigue, joint pain, and recent onset of anxiety. 1. Chronic Fatigue - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1: Patient reports debilitating fatigue for the past 6 months, not relieved by rest. Describes it as a constant exhaustion impacting daily activities and work. Started insidiously, worse in the afternoons. - Past medical history, previous surgeries, medications, relevant to issue 1: History of iron deficiency anaemia 5 years ago, treated with oral iron. Currently taking no medications for fatigue. No relevant surgeries. 2. Polyarthralgia - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2: Reports migratory joint pain affecting knees, wrists, and small joints of the hands for the last 3 months. Worse in the mornings with stiffness lasting about 30 minutes. No swelling or redness noted by patient. - Past medical history, previous surgeries, medications, relevant to issue 2: No prior history of arthritis. Uses over-the-counter paracetamol occasionally for pain, with limited relief. No relevant surgeries. 3. Generalised Anxiety - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc: Patient describes new onset of persistent worry and nervousness over the past 2 months, unrelated to specific events. Experiences difficulty sleeping, irritability, and muscle tension. Denies panic attacks or suicidal ideation. - Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc: No prior history of anxiety or depression. No psychiatric hospitalisations. No medications for anxiety. Past history: Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments: Iron deficiency anaemia (resolved), childhood asthma (well-controlled, no current inhalers), appendectomy at age 12. No current regular medications apart from occasional paracetamol. Family history: Relevant past family history and social history: Mother has hypothyroidism and rheumatoid arthritis. Father had hypertension. Patient is a non-smoker, rarely drinks alcohol. Works as a primary school teacher. Lives with partner and two children. Reports moderate stress levels at work. Examination: Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable): T 36.8°C, Sats 98% on air, HR 78 bpm, BP 128/82 mmHg, RR 16 breaths/min. - Physical or mental state examination findings, including system specific examination: General appearance: Tired but well-nourished. Skin: No rashes or pallor. Cardiovascular: S1/S2 audible, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no organomegaly. Musculoskeletal: Full range of motion in affected joints, no warmth, swelling or erythema. Mild tenderness on palpation of knee and wrist joints. Neurological: Cranial nerves intact, normal tone and power, reflexes 2+, no sensory deficits. Mental State Examination: Alert and oriented, mood anxious, affect constricted, thoughts logical, no perceptual disturbances. - Negative findings mentioned on examination: No joint effusions, no skin changes, no lymphadenopathy. Impression: Working diagnosis: Possible autoimmune disease (e.g., early rheumatoid arthritis or lupus) contributing to fatigue and arthralgia, complicated by generalised anxiety disorder. Differential diagnoses: Chronic fatigue syndrome, fibromyalgia, hypothyroidism, B12 deficiency, other systemic inflammatory conditions. Plan: Lifestyle & education: Advised on gentle exercise, stress reduction techniques (mindfulness, breathing exercises), and maintaining a regular sleep schedule. Educated on the potential links between physical and mental health symptoms. Medications: Continue paracetamol as needed for pain. Discussed possibility of SSRI for anxiety if symptoms persist or worsen after lifestyle modifications. Further investigations: Full blood count, ESR, CRP, Thyroid stimulating hormone (TSH), Vitamin B12, Ferritin, ANA, Rheumatoid Factor, anti-CCP antibodies. Urine dipstick. Liver and renal function tests. Referrals: Referral to Rheumatology for further evaluation of polyarthralgia and fatigue. Consider referral to talking therapies (CBT) if anxiety symptoms do not improve. Follow-up: Review in 2 weeks with blood test results to discuss findings and adjust management plan. Safety netting: Advised to seek urgent medical attention for any new or worsening symptoms, particularly severe pain, swelling, fever, or thoughts of self-harm.
[Age and Gender] [seen with] [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [1. Issue, problem or request 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Past medical history, previous surgeries, medications, relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [2. Issue, problem or request 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Past medical history, previous surgeries, medications, relevant to issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [3. Issue, problem or request 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past history: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Possible medication side effects if explicitly mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family history: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant past family history and social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Physical or mental state examination findings, including system specific examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Findings from the physical examination, including vital signs and any abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Negative findings mentioned on examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Only put examination findings in once] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Likely diagnosis for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Differential diagnosis for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Investigations: Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Impression: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Lifestyle & education: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Further investigations: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Referrals: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Follow-up: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Safety netting: (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.)
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Specialty

Family Medicine Specialist

Used

8 times

Type

Note

Last edited

21/1/2026

Created by

Heidi Team

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