Ambulatory Clinic Note

Chief Complaint: [Specific question or reason for the visit to the clinic] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) History of Presenting Illness: [State the patient's age and relevant past medical history. Detailed history of the presenting illness in narrative form, including onset, provoking factors, quality, radiations, severity, and time course.] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Past Medical History: [Relevant past medical history such as HIV, TB, hypertension, diabetes, cardiac disease, asthma, or epilepsy] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Home Medications: [List of current medications including dosages; include chronic medication from clinic or private pharmacy if mentioned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Allergies: [List of known allergies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Social History: [Relevant social history including tobacco (calculate and include the pack year if available), alcohol, recreational drug use, marital status, number of children, sexual activity and contraception, protection during intercourse, sexual orientation, living situation, income source, pets] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Family History: [Relevant family medical history including TB, diabetes, hypertension, cancer, psychiatric illness, or genetic conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Screening: [Include relevant national or institutional screening, e.g., Pap smear (as per South African cervical cancer screening guidelines), mammogram, prostate-specific antigen (PSA), TB screening, HIV testing, diabetes and hypertension screening, and colorectal cancer screening if relevant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Vaccinations: [COVID-19, influenza, pneumococcal, tetanus/diphtheria/pertussis (TdaP), HPV, Hepatitis B, as per EPI or adult vaccination recommendations in South Africa] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) PHQ 9: [Insert PHQ 9 score] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) STEADI Fall Risk: [risk of fall: high, medium, or low] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Mini-Cog: [Insert Mini-Cog Score] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) ASCVD score or MESA-CAC Score: [risk percentage if cardiovascular risk was calculated] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit completely.) Assessment/Plan: 1. [Issue, request, or condition name] [Impression] [Differential diagnosis] [Investigations planned] [Treatment planned] [Relevant referrals] (Only include any of the above if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit each item entirely.) 2. [Issue, request, or condition name] [Impression] [Differential diagnosis] [Investigations planned] [Treatment planned] [Relevant referrals] (Only include any of the above if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit each item entirely.) 3. [Issue, request, or condition name] [Impression] [Differential diagnosis] [Investigations planned] [Treatment planned] [Relevant referrals] (Only include any of the above if explicitly mentioned in transcript, contextual notes, or clinical note; otherwise omit each item entirely.) Billing Codes: (Only include if explicitly mentioned in transcript or clinical 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 a 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.)