(Throughout this note, bold all section headings written within asterisks "**")
I had the pleasure of seeing [patient name] today. [patient pronoun] is a pleasant [patient age] year old [patient gender] that was referred for cardiac assessment.
**CARDIAC RISK FACTORS**
Increased BMI: [Mention whether there's increased BMI] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Hypertension: [Mention whether there's hypertension] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Dyslipidemia: [Mention whether there's dyslipidemia] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Diabetes mellitus: [Mention whether patient has diabetes mellitus] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Smoker: [number of pack-years if mentioned and state number of years smoked and number of cigarettes or packs per day if available] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
(only include if patient is not currently smoking, otherwise omit this ex-smoker section) Ex-smoker: [state the year they quit if mentioned and whether they quit remotely] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Family history of atherosclerotic disease in first-degree relatives: [mention if patient's mother, father, sister, brother or child had a myocardial infarction, coronary angioplasty, coronary stenting, coronary bypass, peripheral arterial procedure, or stroke prior to age 55 in men or 65 in women] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
**CARDIAC HISTORY**
[List cardiac diagnoses in order, including heart failure (HFpEF, HFrEF), cardiomyopathy, arrhythmias (atrial fibrillation, atrial flutter, SVT, VT, AV block, heart block), devices (pacemakers, ICDs), valvular disease, endocarditis, pericarditis, tamponade, myocarditis, and coronary disease.] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
[For heart failure, specify HFpEF or HFrEF, whether an ICD was implanted, including date and model.] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
[For atrial or ventricular arrhythmia, include history of cardioversions and ablations (type and date).] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
[For AV block, heart block, or syncope, state if a pacemaker was implanted, including type, model, and date.] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
[For valvular heart disease, note the type of intervention and date.] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
[For coronary disease, summarize previous angiograms, coronary anatomy, and interventions (angioplasty, stenting, CABG) with graft details and dates.] (Use verbatim if available in context; update only if new information is in the transcript. If no prior context, include only if explicitly mentioned; otherwise, leave blank and omit.)
**OTHER MEDICAL HISTORY**
[list other relevant medical history that is not cardiac related. Include previous surgeries and associated year if known. For any historical non-cardiac diagnoses, include the associated year if known] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
**CURRENT MEDICATIONS**
Antithrombotic Therapy: [include any current use of antithrombotics including aspirin, clopidogrel, ticagrelor, prasugrel, apixaban, rivaroxaban, dabigatran, edoxaban, warfarin. For all current medications, include doses, frequency, and administration if mentioned] [include the typical recommend dosage per tablet or capsule in parentheses in the same line per medication if it differs from the patient's dose] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. list medications in one line. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Antihypertensives: [include any current use of antihypertensives including ace inhibitors, arbs, beta blockers, calcium channel blockers, alpha blockers, nitrates, diuretics that are not furosemide such as HCTZ/chlorthalidone/indapamide. For all current medications, include doses, frequency, and administration if mentioned] [include the typical recommend dosage per tablet or capsule in parentheses in the same line per medication if it differs from the patient's dose] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. list medications in one line. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Heart Failure Medications: [include any current use of heart failure medications including Entresto, SGLT2 inhibitors, mineralocorticoid receptor antagonists, furosemide, metolazone, ivabradine. For all current medications, include doses, frequency, and administration if mentioned] [include the typical recommend dosage per tablet or capsule in parentheses in the same line per medication if it differs from the patient's dose] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. list medications in one line. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Lipid Lowering Medications: [include any current use of heart failure medications including statins, ezetimibe, PCSK9 modifiers, fibrates, icosapent ethyl. For all current medications, include doses, frequency, and administration if mentioned] [include the typical recommend dosage per tablet or capsule in parentheses in the same line per medication if it differs from the patient's dose] (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. list medications in one line. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
[any other current medications that are not mentioned above] (repeat similar structure as above current medication sections. list medications in one line.)
**ALLERGIES AND INTOLERANCES**
[list allergies and medication intolerance. If a reaction is mentioned, include it in parentheses besides the respective allergy] (list allergies in sentence format separated by commas) (if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
**SOCIAL HISTORY**
[Detail patient's social history. include where patient lives, spousal arrangements, number of children, working arrangements, retirement status, smoking status, alcohol status, illicit or recreational drug use status, and whether they have a private drug or health plan. include comment on ADLs and IADLs if relevant. if patient smokes or is an ex-smoker then write "Smoking history as above.". if there is no history of smoking, write "Non-smoker.", if patient drinks alcohol then write the number of drinks per day or week, if stated] (Write this section in short-paragraph narrative form; if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
**HISTORY**
[mention and describe all the reasons for current visit or chief complaints with a very detailed history of presenting illness and include mentioned negatives from exams and symptoms. Include any information on physical activities and exercise regiments] (write in narrative style, paragraph form using as many complete sentences as needed. Only include if explicitly mentioned in the transcript and contextual notes.)
"Review of systems is otherwise non-contributory."
**PHYSICAL EXAMINATION**
[Vital signs including blood pressure, heart rate, oxygen saturation] (Only include if explicitly mentioned in the transcript) [Cardiac examination insights] (Only include cardiac exam insights if explicitly mentioned in the transcript, contextual notes or clinical note. if not mentioned or exam was normal, then write "Precordial examination was unremarkable with no significant heaves, thrills or pulsations. Heart sounds were normal with no significant murmurs, rubs, or gallops.") [Respiratory examination insights](Only include respiratory exam insights if explicitly mentioned in the transcript, contextual notes or clinical note. if not mentioned or exam was normal, then write "Chest was clear to auscultation.") [Peripheral edema insights](Only include peripheral edema insights if explicitly mentioned in the transcript, contextual notes or clinical note. if not mentioned or exam was normal, then write "No peripheral edema.") [Any other physical exam insights](Only include peripheral edema insights if explicitly mentioned in the transcript, contextual notes or clinical note. Omit if not mentioned) (write all together in short-paragraph, narrative form)
**INVESTIGATIONS**
Laboratory investigations: [laboratory investigation findings and dates. List in following order if available: CBC, electrolytes, creatinine with GFR if mentioned, troponins, NTpBNP or BNP level, A1c, lipids, other labs mentioned] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
ECGs: [ECG findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. Only include if explicitly mentioned in the transcript, otherwise write "None known")
Echocardiograms: [Echocardiogram findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Stress tests: [Stress test findings and dates, including stress echocardiograms and graded exercise challenges] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Holter monitors: [Holter monitor findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks; if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Device interrogations: [Device interrogation findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Cardiac perfusion imaging: [Cardiac perfusion imaging findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Cardiac CT: [Cardiac CT findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Cardiac MRI: [Cardiac MRI findings and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
Other investigations: [Other relevant investigations and dates] (include dates in parentheses followed by a colon in one single line without line breaks. if information is available in context, write verbatim word-for-word what exists in context and only include information from the transcript if it differs or is an update from prior contextual notes. If information is not available in context, only include if explicitly mentioned in the transcript, otherwise write "None known")
**SUMMARY** (write below summary section all together as a cohesive narrative story)
[patient name] is a pleasant [age] year old [gender] that was seen today for cardiac assessment. ["Cardiac risk factors include" list of cardiac risk factors] (only include if mentioned in transcript or context, otherwise leave blank)
[Summarize patient symptoms and cardiac investigations] (use what is mentioned in the above "cardiac history" section and "investigations" section respectively. If not present, leave blank)
**ASSESSMENT/PLAN**
[#1 Medical issue 1] (Include condition name, ensuring all information is drawn from context section, transcription and cardiac history heading if relevant. Include the "#" sign)
Assessment: [Assessment] (current assessment of the condition. draw from context section and transcription)
Plan: [Plan] (proposed plan for management, including investigations or follow-up. provide explanations for why the current management plan was chosen; include counselling details if mentioned. Ensure a detailed description where possible drawing from the transcription and context section.)
(for any additional medical issue, repeat the same structure above, and continue the numerical listing)
**FOLLOW-UP**
[Follow-up plan](list follow up plans and time frames based on transcription. if follow up time frame is not explicitly mentioned then write "Will follow-up in due course, pending investigations, or sooner should the need arise.") (only include explicitly from transcript)
"Thank you for the privilege of allowing me to participate in [patient's name] care. Feel free to reach out directly if any questions or concerns."
(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 include 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)
