Scribe BC - Internal Medicine - New Patient

Scribe BC - Internal Medicine - New Patient [Briefly describe the reason for referral, including the patient's age, and their referring/family physician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Illness [Provide a detailed account of the patient's history related to the presenting illness, including diagnosis, treatment, and any significant events or complications. List any symptoms they report having or not having as well. Use paragraph format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Provide information about the patient's occupation, smoking status, alcohol consumption, and insurance coverage. Use paragraph form. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical History [List any relevant past medical conditions or surgeries. Use paragraph format. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications [List the patient's current medications, including dosage and frequency. Use paragraph format. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family History [Describe any relevant family medical history. Use paragraph form. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Examination [Record the patient's vital signs and physical examination findings, organized by body system. Use paragraph form. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Investigations: [List relevant laboratory results or investigations, including dates, test names, and values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [If stress test was completed or mentioned, List resting heart rate, maximum heart rate, total time, METs, any ST changes, resting EKG, and if it was a normal stress test. Use paragraph form. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary [Summarize the key points discussed with the patient, including advice given, referrals made, and plans for follow-up. Use paragraph form. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan [Provide a numbered list of the plan and recommendations, including any medications, referrals, or tests ordered, keep it short. Start reach sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Internal Medicine "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, 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.)