Female AWV Note - Cannon

Chief Complaint: [Capture the major reason for the patient's visit today. If there is more than one, list these in bullet point format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HPI: [Include a detailed explanation of the patient's current medical conditions, including onset, location duration, quality, aggravating factors, relieving factors, timing, and severity. Also include any interventions the patient has already tried to alleviate their symptoms and whether or not these were effective. If the patient has experienced this condition before, make mention of how it was treated last time and whether or not it was effective.] (New diagnoses made today and changes to medications made today should not be mentioned in this section. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (This section should be in numbered bullet point format organized by medical condition. If more than one distinct condition is discussed, organize the separate conditions by numbered bullet point lists.) Female AWV (if any of the following points were not discussed, write "n/a" next to them) - Nutrition: [include details regarding the patient's current diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Exercise: [include details regarding the patient's current exercise regimen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Falls: [include any mention of recent falls along with any associated injuries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - EtOH/Tobacco: [include details regarding the patient's current use of alcohol and tobacco] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - HTN screen: [include details regarding the patient's blood pressure today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cholesterol: [include details regarding the patient's most recent LDL levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - 10 year CV risk %: [if a 10-year ASCVD risk is mentioned, list it here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Pap Smear: [if obtaining a Pap smear was discussed, mention that decision here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Taking Folate?: [if the patient mentioned that she is taking folate, mention that here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Teratogenic Meds: [if the patient is taking any teratogenic meds, mention them by name here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Contraceptive method: [if the patient's method of contraception was discussed, mention it here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - STD screen: [if the patient requests STD screening today, mention it here. Also include any recent STD screening results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - One time HIV/HBV/HCV screen: [if the patient has ever been screened for HIV, HCV, or HBV, mention those results here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Skin cancer screening: [mention any lesions concerning for possible skin cancer here] (if no lesions are mentioned, omit this line) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Depression (PHQ2/9): [if symptoms of depression or a score on the PHQ2 or PHQ9 questionnaires are mentioned, detail those here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Anxiety (GAD2/7): [if symptoms of anxiety or a score on the GAD2 or GAD7 questionnaires are mentioned, detail those here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Med review: [if the patient's medications were confirmed with them, say "medication list reviewed and confirmed"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Mammogram: [if obtaining a screening mammogram was discussed, mention that decision here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - DEXA: [if obtaining a DEXA was discussed, mention that decision here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Colon CA screen: [if obtaining either a screening colonoscopy or Cologuard test was discussed, mention that decision here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lung CA Screen: [if screening for lung cancer was discussed, mention those details here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Advance Care Planning: [if an advance directive was discussed, mention those details here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical Diagnoses: [Include a numbered list of the patient's medical diagnoses made prior to today's appointment.] (Organize this list by relevance to today's visit. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Specialist Care: [If patient is seeing any medical specialists, list them here in number list format. Include name and specialty.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: [Include a numbered list of the medications the patient has been taking prior to today's visit including current dose and frequency. Use standard medical abbreviations.] (If none are mentioned, exclude this section and its heading. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Substances: [Include a numbered list of the illicit, non-prescription substances the patient has been using prior to today's visit.] (If none are mentioned, exclude this section and its heading. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Supplements: [Include a numbered list of the nutritional supplements the patient has been taking prior to today's visit.] (If none are mentioned, exclude this section and its heading. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Systems (This section should not include interpretations by the patient or physician. It should only include subjective signs and symptoms mentioned by the patient.) Constitutional: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No fever, chills, fatigue, or weight changes.") Eyes: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No vision changes, redness, pain, or discharge.") Ears, Nose, Throat: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.") Cardiovascular: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No chest pain, palpitations, or edema.") Respiratory: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No shortness of breath, cough, or wheezing.") Gastrointestinal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No nausea, vomiting, diarrhea, constipation, or abdominal pain.") Genitourinary: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No dysuria, hematuria, urinary frequency, or urgency.") Musculoskeletal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No joint pain, stiffness, or swelling.") Skin: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No rashes, lesions, or itching.") Neurologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No headaches, dizziness, numbness, or weakness.") Psychiatric: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No anxiety, depression, or mood changes.") Endocrine: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No polyuria, polydipsia, or heat/cold intolerance.") Hematologic/Lymphatic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No easy bruising, bleeding, or lymphadenopathy.") Allergic/Immunologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No allergies, sneezing, or hives.") Physical Exam (Include both normal and abnormal findings explicitly mentioned in the transcript. Use proper, medical terminology. Only include headings for organ systems that are explicitly examined in the transcript. Leave out systems that are not mentioned. Do not include interpretations mentioned by the patient or physician, only objective signs and symptoms.) Constitutional: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Vital Signs: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] [Include specific values if mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Head: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eyes: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ears, Nose, Throat: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neck: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cardiovascular: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Respiratory: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Gastrointestinal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Genitourinary: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Musculoskeletal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (If specific joints, muscles, tendons, or ligaments are mentioned, create a specific bullet point for them and their exam findings. Be as specific as possible regarding these findings. Include the names of specific exam maneuvers and their results if mentioned by the physician. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Skin: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neurologic: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Psychiatric: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Labs / Imaging / Diagnostic Tests: [Include a numbered list of recent labs, bloodwork, imaging, and diagnostic test results which occurred prior to today's visit. Be as specific as possible. If mentioned in the transcript, include when the next follow up test should be conducted. Capture and detail any trends mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment & Plan (This entire section should use detailed, proper medical terminology. The first problem listed should always be Preventive Care.) 1. [Medical Diagnosis #1] [include the ICD10 code for this diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: [Include a detailed assessment of this specific condition in paragraph style using complete sentences.] (When a diagnosis has not been confirmed with labs or imaging, include a differential diagnosis of 3 possible diagnoses in order of most likely to least likely. Include any changes in the condition since prior appointments or with recent interventions. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: (Include a bullet point list for the plan with regard to this specific problem. Include all medications related to this problem and any changes in their dosing today. Also include labs, tests, and referrals ordered today. If specific timeframes were discussed, mention these as well. Only include items specifically mentioned by the physician. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (continue this pattern for all problems discussed in this visit) Procedure Note: (Only include this section if a procedure was performed during today's office visit. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient Name: [Insert patient name] Date of Procedure: [Insert date] Procedure Performed: [Insert procedure name] Indication: [Insert reason for procedure] Pre-Procedure Diagnosis: [Insert diagnosis or condition] Post-Procedure Diagnosis: [Insert diagnosis, typically same as pre-procedure unless findings differ] Details of Procedure: Consent: Informed consent was obtained, including discussion of risks, benefits, and alternatives. Preparation: [Insert preparation details, e.g., sterile technique, patient position, local anesthetic used]. Procedure Steps: [Describe the procedure in brief, step-by-step fashion]. Findings: [Insert findings, if any]. Complications: None. [Insert any complications if applicable.] Post-Procedure Care: Patient tolerated the procedure well. Post-procedure monitoring: [Insert any specific monitoring or follow-up instructions]. Follow-up plan: [Insert follow-up plan, including any additional diagnostics or visits]. Medications Administered: [Insert medications, dosages, and route if applicable]. (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)