Diabetes Clinic Review Summary - Sharwood

Full review documented in Diabetes Outpatient Powerform Summary: [Insert patient name], [Insert patient age] (Only include if explicitly mentioned in transcript or context, else omit.) Attended with [Insert companion details, e.g. parent/guardian/sibling] (Only include if explicitly mentioned in transcript or context, else omit.) Diagnosis history: - T1DM for [Insert duration]; diagnosed [Insert age or year] (Only include if explicitly mentioned in transcript or context, else omit.) - Coeliac disease: [Insert status] (Only include if explicitly mentioned in transcript or context, else omit.) - Thyroid disease: [Insert status] (Only include if explicitly mentioned in transcript or context, else omit.) Anthropometry: - Height: [Insert height] (Only include if explicitly mentioned in transcript or context, else omit.) - Weight: [Insert weight] (Only include if explicitly mentioned in transcript or context, else omit.) - Blood pressure: [Insert BP] (Only include if explicitly mentioned in transcript or context, else omit.) Current management: - [Insert insulin regimen summary] (Only include if explicitly mentioned in transcript or context, else omit.) - Total daily dose: [Insert units] units; [Insert value] units/kg/day - Basal insulin: [Insert basal units] units ([Insert percentage] %) - HbA1c: [Insert value] % - Time in range: [Insert value] % - Glucose monitoring method: [Insert CGM/Flash/fingerprick etc.] (Only include if explicitly mentioned in transcript or context, else omit.) - Other relevant medications or interventions: [Insert details] (Only include if explicitly mentioned in transcript or context, else omit.) Progress: [Summarise patient’s progress and any recent changes since last review] (Only include if explicitly mentioned in transcript or context, else omit. Write in paragraph format.) Pump disconnection plan: - Levemir [Insert units] units BD - Novorapid [Insert ratio] unit : [Insert grams] g - Insulin sensitivity factor (ISF): [Insert value] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Plan: [List any plans including medication changes, review intervals, referrals, and follow-up tests] (Only include if explicitly mentioned in transcript or context, else omit. Write as numbered list.) "Heidi Medical AI Scribe used with patient/guardian consent during the consultation to assist in the preparation of this record. This record/document has been reviewed and finalised by the author." (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 to include in your note. Only include a placeholder if it has been explicitly mentioned in the transcript or context — otherwise omit the section completely. Always write numbers (e.g. insulin doses, percentages, units) in digits not in words. Use paragraphs or bullet points where appropriate to reflect how the information was communicated.)