Scribe BC - Generic Clinic note

**Reason for Visit** [Summarise the patient’s stated reason for consultation, concerns, and any presenting symptoms or follow-up purpose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Consent** "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks" **History of Present Illness (HPI)** [Provide a structured summary of current symptoms or concerns, their onset, duration, pattern, aggravating or relieving factors, severity, and any attempts at self-management or previous evaluation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as thematic paragraphs in full sentences.) **Physical Examination** - **General:** [Overall appearance, vital signs, body habitus] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Cardiovascular:** [Heart sounds, blood pressure, pulse, peripheral perfusion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Respiratory:** [Breath sounds, respiratory effort, auscultation findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) - **Gastrointestinal:** [Abdominal findings including tenderness or organomegaly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Neurological:** [Orientation, strength, sensation, coordination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) - **Other:** [Skin integrity, musculoskeletal exam, foot health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Lab Results** - [List relevant laboratory results with any trends, e.g. glucose, lipids, renal function, liver function, inflammatory markers, specialty-specific tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Past Medical History** - [List relevant chronic conditions or previous diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Procedure / Surgical History** - [List past surgeries or procedures relevant to current care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) **Medications** - [List current medications including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) **Allergies** - [List medication or substance allergies and nature of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) **Diagnostics** - [Imaging reports (e.g., CT, MRI, PET) with summary interpretation and dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) **Assessment / Plan** 1. [Brief summary of working diagnosis and interpretation of findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. ) 2. [Outline of investigations, referrals, or treatments to be initiated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. [Management of symptoms or chronic conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. [Timeframe for follow-up and safety netting instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never invent patient details, assessments, plans, interventions, evaluations, or ongoing care. Use only the transcript, contextual notes, or clinical note as your source. If any placeholder lacks data, omit it completely. Follow this template exactly to prevent hallucinations or misinterpretation. Preserve markdown formatting.)