NWRI

NON-WORK RELATED INJURY/ILLNESS Days left on swing: [how many days left on site, when they go home, how much longer on their swing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a single line.) Employer: [who they work for and which department] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a single line.) Role: [job role] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a single line.) Meds: [list all current medications mentioned] (If no medications explicitly mentioned in transcript, contextual notes or clinical note, write "As recorded". If additional medications are mentioned, list all medications explicitly.) Allergies: [list all allergies mentioned] (If no allergies explicitly mentioned in transcript, contextual notes or clinical note, write "As recorded". If additional allergies are mentioned, list all allergies explicitly.) Relevant Past History: [describe relevant past medical history mentioned] (If no past history explicitly mentioned in transcript, contextual notes or clinical note, write "As recorded". If additional past history is mentioned, include all relevant past history.) HPC: [describe the patient's concern or the identified issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.) Exam: [document key subjective and objective findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences. Use descriptive terms such as afebrile if fever is discussed but no temperature value is given.) General: [describe constitutional symptoms including weight change, fever, chills, night sweats, fatigue, malaise] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Eyes: [describe eye-related symptoms including pain, swelling, redness, discharge, vision changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) ENT: [describe hearing changes, ear pain, nasal congestion, sinus pain, sore throat, hoarseness, swallowing difficulty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Cardiovascular: [describe chest pain, SOB, palpitations, orthopnoea, PND, oedema, claudication] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Respiratory: [describe cough, sputum, wheeze, smoke exposure, dyspnoea] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Gastrointestinal: [describe nausea, vomiting, diarrhoea, constipation, abdominal pain, heartburn, dysphagia, bleeding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Genitourinary: [describe dysuria, frequency, hematuria, incontinence, urgency, flank pain] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Musculoskeletal: [describe arthralgia, myalgia, joint swelling/stiffness, back/neck pain, injury history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Integumentary: [describe skin or wound findings including lesions, pruritus, hair changes, wound description, signs of infection, wound size and location] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences. List multiple wounds individually.) Neurological: [describe weakness, numbness, dizziness, headache, loss of consciousness, coordination changes, recent falls] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Psychiatric: [describe anxiety, depression, insomnia, delusions, suicidal/homicidal ideation, abuse history, eating concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Endocrine: [describe polyuria, polydipsia, temperature intolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Hematologic/Lymphatic: [describe bruising, bleeding, lymphadenopathy, transfusion history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Allergic/Immunologic: [describe allergic reactions, autoimmune disorders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Obs: [record blood pressure, heart rate, temperature, oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line with values separated by commas.) General Exam Findings: [describe other general observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) System-specific Exam: [describe findings from CVS, respiratory, abdominal, CNS or other systems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences grouped under each system examined.) Impression: [state the problem or initial diagnosis, including revised diagnosis if the impression changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences. If diagnosis changes, list both initial and revised diagnoses.) Consult: [record which doctor was consulted by phone, typically Dr Charl] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a single line.) Plan: [outline the plan including specific drug doses, route, frequency, treatment duration, wound care or other instructions explicitly mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences or bullet points. Begin with "Reassurance provided" if reassurance was discussed.) Review: [specify review plan and timeframe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If no review specified, write "NA".) (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.) (Exclude direct quotations from the patient except when describing subjective complaints. Remove or rephrase coarse language professionally.)