GP Telephone Consult

Telephone Consultation [Insert participants such as patient, parent, carer, partner] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Reason for Call: [Reason for the call] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Subjective: [Current issues, reasons for consultation, discussion topics, and history of presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Past medical history and previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Current medications, including over-the-counter or herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Laboratory results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Imaging results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: Assessment: [Diagnosis or clinical impression as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) [Treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Medications prescribed or adjusted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Referrals made or advised] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)