Dr. Dad Annual Exam V3 (BILH)

(ALWAYS output this note in the exact same layout and structure as below.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is always historical data from previous sessions with this patient.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Subjective: [Patient name] is a [age] y.o. [gender] here for [specify type of exam: annual, follow-up][describe how the patient is feeling] (use appropriate pronouns to describe patient) [state if the patient has new concerns and what those concerns are.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.) [State patient's emotional status, things in their life that are affecting their emotional state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Begin with a brief introduction summarizing the patient’s overall clinical context and medical history] (The information in the Context tab is all historical data from previous sessions with this patient.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in narrative form using subjective language, and use as many sentences and paragraphs as needed to capture all detail.) (For the following section, each problem or issue mentioned in the transcript or contextual notes must be presented as a separate paragraph, categorised by organ system. Begin with a summary of relevant discussions from previous sessions based on the contextual notes. Next, document any specialist consultations, treatments, or investigations the patient has undergone for this issue since their last review. Conclude with any new subjective information the patient has shared during today's session, such as new symptoms, interval changes, improvements etc. Never include today’s assessment, recommendations, counselling, plans, or referrals discussed in the transcript in this section - these should always be documented in the Assessment & Plan section only.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summarize relevant historical data relating to issue 1 from previous sessions, including any related specialist visits since last session.][Describe any new subjective findings related to this issue reported by the patient in today’s session.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned. Always write this section using subjective language and a narrative style, including as many sentences and paragraphs as required to capture all details. Never include recommendations, counselling, or plans derived from today's consultation in this section - this should always be included in the Assessment & Plan section only.) [Summarize relevant historical data relating to issue 2 from previous sessions, including any related specialist visits since last session.][Describe any new subjective findings related to this issue discussed in today’s session.](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned. Always write this section using subjective language and a narrative style, including as many sentences and paragraphs as required to capture all details. Never include recommendations, counselling, or plans derived from today's consultation in this section - this should always be included in the Assessment & Plan section only. Continue for as many issues as required to capture all details.) [describe current diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. The information in the Context tab is all historical data from previous sessions with this patient. Write this section in narrative form, using subjective language and as many sentences as needed.) [list any other specialty the patient is being reviewed by and the current concerns the other providers are addressing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. The information in the Context tab is all historical data from previous sessions with this patient. Write this section in narrative form, using subjective language and as many sentences as needed.) [insert interval medical history from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert last Assessment & plan from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert medication and allergies from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert past medical history from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert past surgical history from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert family history from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert social history from the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [alcohol use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [smoking history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [drug use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [insert Wt Readings from Last 3 Encounters](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) [insert BP Readings from Last 3 Encounters] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (The information in the Context tab is all historical data from previous sessions with this patient) Review of Systems: General: [describe overall appearance and condition] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Eyes: [describe findings related to vision and eye health] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Ears/Nose/Throat: [describe findings related to the ears, nose, and throat] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Cardiovascular: [describe findings related to the cardiovascular system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Respiratory: [describe findings related to the respiratory system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Gastrointestinal: [describe findings related to the gastrointestinal system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Genitourinary: [describe findings related to the genitourinary system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Musculoskeletal: [describe musculoskeletal symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Skin: [describe findings related to the skin] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Neurology: [describe findings related to the neurological system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Hematology: [describe findings related to hematology] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Psychiatric: [describe findings related to psychiatric symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Endocrine: [describe findings related to the endocrine system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Physical Exam: Constitutional: [describe overall appearance and condition] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Head: [describe head findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Eyes: [describe eye findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Ears: [describe findings related to ears] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Nose: [describe findings related to the nose] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Mouth: [describe findings related to the mouth] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Neck: [describe findings related to the neck] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Cardiovascular: [describe cardiovascular findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Respiratory: [describe respiratory findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Chest Wall: [describe chest wall findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Abdomen: [describe abdominal findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Neck, Spine, Ribs, Pelvis: [describe findings related to neck, spine, ribs, and pelvis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Extremities: [describe findings related to extremities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Neurological: [describe neurological findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Psychiatric: [describe psychiatric findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Skin: [describe skin findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Breasts: [describe breast findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Assessment & Plan: [Patient name] is a [age] y.o. [gender] here for [specify type of exam: annual, follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.) (The current Assessment & Plan section contains a numbered list of medical conditions as subheadings and under each condition, bullet points will be listed containing assessment and plan information pertinent to that condition. You must include the entire Assessment & Plan from the previous session verbatim here. Do not modify, remove, or restructure any part of the previous session’s content. This includes all conditions and their respective bullet points, even if certain sections were left blank or were not discussed in today's session. Maintain the exact structure and wording. After the previous session's content is copied verbatim, add new bullet points under each condition to reflect today's updates. These additions should capture any changes in the treatment plan, medication adjustments, continuation of care, follow-up tests, diagnostic evaluations, imaging, blood work, or any other relevant management details.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 1. [Condition 1 Name exactly as written in previous Assessment & Plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Always write this exactly as written in the contextual notes, never alter this in any way.) [Verbatim copy of the previous session's bullet points for this condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Always write this exactly as written in the contextual notes, never alter this in any way.) - [New bullet point(s) added based on today's session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Only include additional information based on the transcript. Never come up with your own assessment or plan.) 2. [Condition 2 Name exactly as written in previous Assessment & Plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Always write this exactly as written in the contextual notes, never alter this in any way.) [Verbatim copy of the previous session's bullet points for this condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Always write this exactly as written in the contextual notes, never alter this in any way.) - [New bullet point(s) added based on today's session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Only include additional information based on the transcript. Never come up with your own assessment or plan.) (Repeat this structure for all conditions in the plan. If there are no new updates for a condition, simply retain the previous session’s content without any modifications. Do not state that there are no updates—just carry forward the previous plan verbatim. If you do not copy the previous session’s Assessment & Plan verbatim before adding new bullet points, your output is incorrect and must be revised. Never remove any subheadings or bullet points from the previous sessions Assessment & Plan.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own assessment, plan, interventions, evaluation, or plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference. ) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Labs as ordered: [write a list of the labs to be ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Vaccinations: [write a list of the vaccinations patient will receive or denies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Follow up in [date of follow up] for [reason for follow up]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.) “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools at future visits.” (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write this verbatim.) (Disclaimer: 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.)