CMA criteria:
Patient consent.
Patient provided verbal consent for the consultation, which was documented in the patient's electronic health record.
Patient history.
* Patient reports a history of hypertension diagnosed five years ago.
* Patient denies any history of smoking or illicit drug use.
* Patient reports a family history of type 2 diabetes in their mother.
Medical conditions.
* Hypertension, well-controlled with medication.
* Mild osteoarthritis in the right knee.
Physical, psychological and social function.
* Patient ambulates independently.
* Patient reports feeling anxious about work-related stress.
* Patient lives with their spouse and has a strong social support network.
Interventions and referrals
* Prescribed lisinopril 10mg daily for hypertension.
* Referred patient to a local counselling service for stress management.
Preventive healthcare management plan for the patient.
* Recommend annual influenza vaccination.
* Recommend blood pressure check every six months.
* Discussed importance of regular exercise and a balanced diet.
* Scheduled follow-up appointment in three months to review blood pressure and discuss progress with counselling.
CMA criteria:
Patient consent.
[document patient consent, including how it was obtained and recorded] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single sentence.)
TPatient history.
[document the patient's comprehensive history, encompassing medical, social, and family aspects, and any relevant past events or experiences] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
Medical conditions.
[document all current and past medical conditions, including diagnoses, onset, severity, and current status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
Physical, psychological and social function.
[document details regarding the patient's physical capabilities and limitations, psychological state, and social interactions or support systems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
Interventions and referrals
[document any interventions initiated, including specific treatments or therapies, and details of any referrals made, including the specialty or provider referred to and the reason for referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points, with each point detailing an intervention or referral.)
Preventive healthcare management plan for the patient.
[document the comprehensive preventive healthcare management plan, including recommended screenings, vaccinations, lifestyle modifications, and any future follow-up plans] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
(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 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.)