Consent for use of AI notetaking obtained
Presents for Annual Health Check
Significant life events/changes in last year:
- Patient reports the recent loss of her husband, which has significantly impacted her emotional well-being. She has also moved to a new apartment.
Current Issues:
- Patient reports feeling low in mood and experiencing some social isolation since the death of her husband. She also reports occasional headaches.
Health and/or life goals in next 12 months:
- Patient would like to improve her mood and increase her social activities. She is also considering joining a walking group.
Relevant Previous Medical History:
- Hypertension, managed with medication. Previous history of a fractured wrist.
Relevant Family History and risk factors for chronic disease:
- Father had a history of heart disease. Mother had type 2 diabetes.
Medications:
- Lisinopril 20mg daily, Paracetamol as needed for headaches.
Allergies:
- No known allergies.
Relevant Social History:
- Patient is a widow. She lives alone. She is a non-smoker and drinks alcohol occasionally.
Diet, Exercise, Sleep and Substances:
- Patient reports a balanced diet. She does not exercise regularly. She sleeps approximately 7 hours per night. She drinks alcohol socially.
Mental Health and Well-being:
- Patient reports low mood and feelings of loneliness. She denies any suicidal ideation. She is experiencing grief following the death of her husband.
Immunisations:
- Up to date with influenza and COVID-19 vaccinations. Requires pneumococcal vaccination.
Investigations and screening:
- Blood pressure check performed today. Routine blood tests due. Mammogram due in 6 months.
Other care providers:
- Attends a local bereavement group once a week.
- Currently under a chronic disease management plan for hypertension.
Physical examination:
- Blood pressure: 130/80 mmHg, Heart rate: 72 bpm, Respiratory rate: 16 breaths/min, Temperature: 37°C, Oxygen saturation: 98% on room air.
- General appearance: Alert and oriented, appears her stated age.
- Document findings from physical examination: Cardiovascular: Regular rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender.
Assessment:
- Summarize health status, including any diagnoses or conditions: Hypertension, grief, low mood.
- Mention any risk factors identified: Family history of heart disease and type 2 diabetes.
- For each chronic condition, list management goals and actions for the patient, treatment and services the patient will need, arrangements for providing the treatment and services (including information on other health providers), and when review is needed: Hypertension: Continue Lisinopril 20mg daily. Monitor blood pressure regularly. Review in 3 months. Grief/Low mood: Encourage participation in bereavement group. Consider referral to a counsellor. Review in 1 month.
Plan:
- Outline recommended screenings or tests: Routine blood tests, mammogram in 6 months, pneumococcal vaccination.
- Describe lifestyle or dietary recommendations: Encourage regular exercise, healthy diet, and social interaction.
- Mention follow-up appointments or referrals: Follow-up appointment in 1 month to review mood and grief. Referral to a counsellor.
- Document any prescribed medications or changes to current medications: No changes to current medications.
- Specifically document responses to any questions asked and advice given about planned overseas travel, Vaccination status, Contraception/ Sexual health, pregnancy planning, Eye checks, Dental checks, Mammograms, bone health and bowel screening: Discussed the importance of maintaining current vaccinations. Advised on the importance of regular dental and eye checks. Discussed the importance of bowel screening.
Consent for use of AI notetaking obtained
Presents for Annual Health Check
Significant life events/changes in last year:
- [describe any significant life events, health challenges and changes in last year or since last health check] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Current Issues:
- [describe current issues and concerns] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Health and/or life goals in next 12 months:
- [describe any plans to goals voiced, including plans for travel, pregnancy, work changes etc if mentioned] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Relevant Previous Medical History:
- [describe past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Relevant Family History and risk factors for chronic disease:
- [describe family history and risk factors discussed] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Medications:
- [mention medications and herbal supplements, past and current] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Allergies:
- [mention allergies] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Relevant Social History:
- [describe social history] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Diet, Exercise, Sleep and Substances:
- [describe details discussed about Diet, Exercise, Sleep, alcohol and other drugs] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Mental Health and Well-being:
- [describe details discussed about Mental Health and Well-being] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Immunisations:
- [list immunisations] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Investigations and screening:
- [describe investigations and screening tools/tests which have been done and which are due] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Other care providers:
- [list any other doctors. allied health providers, or other services involved in care including role and frequency of appointments] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
-[note if currently under a chronic disease management plan or if eligible] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Physical examination:
- [record vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation] (only include record vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe general appearance] (only include describe general appearance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [document findings from physical examination] (only include document findings from physical examination if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [note any abnormal findings] (only include note any abnormal findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment:
- [summarize health status, including any diagnoses or conditions] (only include summarize health status, including any diagnoses or conditions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention any risk factors identified] (only include mention any risk factors identified if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [for each chronic condition, list management goals and actions for the patient, treatment and services the patient will need, arrangements for providing the treatment and services (including information on other health providers), and when review is needed] (Only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)
Plan:
- [outline recommended screenings or tests] (only include outline recommended screenings or tests if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe lifestyle or dietary recommendations] (only include describe lifestyle or dietary recommendations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention follow-up appointments or referrals] (only include mention follow-up appointments or referrals if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [document any prescribed medications or changes to current medications] (only include document any prescribed medications or changes to current medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Specifically document responses to any questions asked and advice given about planned overseas travel, Vaccination status, Contraception/ Sexual health, pregnancy planning, Eye checks, Dental checks, Mammograms, bone health and bowel screening)
(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 include 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.) transcript.)
