Patient Details:
[patient full name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[date of birth / age] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[medical record number] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[contact details] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[date of consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Present:
[who is attending and their profession] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.)
1. MyMedicare:
[registration status, whether discussed with patient, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
2. Care Plan:
[care plan status — new, existing, or review required, with follow-up arrangements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
3. Health Screening:
[relevant health assessments (75+, 45–49, Aboriginal/Torres Strait Islander), preventive health screening (mammogram, DEXA, FOBT, CST, PSA) and follow-up requirements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
4. Vaccinations:
[vaccine status including shingles, pneumococcal, influenza, COVID, RSV, age-appropriate vaccines, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
5. Polypharmacy:
[need for Home Medicine Review, referral completion or report received, follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
6. Cardiovascular Risk (CVD):
[risk status, diagnoses, diagnostic results, specialist involvement, monitoring activities, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
7. Falls:
[risk status, diagnoses, assessments, monitoring activities, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
8. Diabetes:
[risk status, diagnoses, pathology results, monitoring activities, specialist involvement, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
9. Social Needs:
[social needs identified including support services, housing, financial, or community resources, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
10. Mental Health:
[risk status, diagnoses, care plan requirements (including review), monitoring activities, and follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
11. Other Issues:
[any other conditions, diagnoses, risk factors, monitoring, or follow-up required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Duration:
[duration of meeting] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in minutes.)
Clinician Details:
[clinician name and role] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[date of completion] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[signature/electronic authentication] (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, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information is not available; simply leave the placeholder blank or omit it completely. Use as many bullet points as necessary to comprehensively capture all relevant details.)