CGA

(Refer to the patient by their name if known) Past Medical History: [Include all relevant past medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list with each condition on a separate line.) Medications: [List all current medications including dosage and frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in one line.) Allergies: [Detail any known allergies and reactions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Psychosocial History: Lives: [detail living arrangements] Children: [insert number], Grandchildren: [insert number] Born in: [insert place of birth] Emigrated to Australia in: [insert year] Personal Activities of Daily Living: [describe status] Domestic ADLs: [describe status] Community ADLs: [describe status] Current services in place: [detail any support services received] Driving: [status] Falls in the last 12 months: [number], Mobility aid: [type], Fall circumstances: [brief description] Educational level: [insert] Employment History: [brief history] EPOA completed: [Yes/No] My Aged Care: [status or referral] Nonsmoker, EtOH: [alcohol intake details] Vaccinations: [vaccination history including flu, COVID, pneumococcal etc.] FHx: [relevant family history] Exercise: [frequency/type] Background: [Include a detailed summary of the patient's history of presenting complaints, reason for referral, and any relevant findings from the consultation.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Assessments: [Describe any assessments or tests conducted during the visit and their results.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Systems Review: Appetite: [patient's appetite status] Weight: [weight status or changes] Mood: [brief comment on mood] Sleeping: [quality and duration] Pain: [presence and severity] Aids used: [mobility or assistive devices] Bowels: [function] Bladder: [function] Memory: [subjective or observed memory status] Pathology: [List any pathology tests requested and their results if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in one line with commas.) O/E: [Document objective findings from the physical examination] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use format: heart rate bpm, blood pressure lying and standing with mmHg, comment on postural drop, neurological findings including tone/power/sensation, peripheral oedema, weight in kg, gait findings.) Cognitive Assessment: [State if cognitive assessment was performed or postponed and provide details] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Issues Discussed During Consultation: - [Brief description and management of issue 1] - [Brief description and management of issue 2] - [Brief description and management of issue 3] - [Brief description and management of issue 4] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use as many bullet points as needed.) Plan / Recommendations: - [Recommended plan of care and any changes to current management] - [Specific recommendations for patient's lifestyle or care adjustments] - [Medication management and monitoring plans] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use one bullet point per plan/recommendation.) (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 from the transcript.)