Virtual Ed - General

"Telehealth consultation" "Id Check - 3 points, Name, DOB, address" "Consent to AI for note taking" Subjective - [reasons for visit and chief complaints] (Such as requests, symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [duration, timing, location, quality, severity, and context of the complaint] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [aggravating and alleviating factors] (Factors that worsen or alleviate the symptoms, including self-treatment attempts and their effectiveness. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [symptom progression] (How the symptoms have changed or evolved over time. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [past occurrences of similar symptoms] (Including when they occurred, how they were managed, and the outcomes. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [functional impact] (How the symptoms affect the patient's daily life, work, and activities. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [associated symptoms] (Any other associated symptoms, focal and systemic, that accompany the reasons for visit and chief complaints. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) Allergies: [allergies] (Write as a list. If no allergies are mentioned in the transcript, context or clinical note, write "NKDA".) Medications: [medications] (Write as a list. If no medications are mentioned in the transcript, context or clinical note, write "Nil".) Past Medical History: - [past medical and surgical history] (Contributing factors including past medical and surgical history, investigations, and treatments relevant to the reasons for visit and chief complaints. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [family history] (Family history that may be relevant to the reasons for visit and chief complaints. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [exposure history] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [immunisation history and status] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [other relevant subjective information] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) Social history: - [social history] (Social history that may be relevant to the reasons for visit and chief complaints. Include smoking or vaping history, alcohol history, and occupation. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) Objective: - [vital signs] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [physical or mental state examination findings] (Including system-specific examinations. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [completed investigations and results] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) Assessment: - [likely diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [differential diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) "Patient has confirmed understanding of diagnosis, plan and safety netting." Plan: - [planned investigations] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [planned treatment] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.) - [other relevant actions] (Such as counselling, referrals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a list.)