GP Note - EMIS

(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript and contextual notes 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 or contextual note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (You must keep all content in the note inside the three defined headings below: 'History:', 'Examination:' and 'Comment:'. You must not generate any additional subsections, headings or subheadings e.g. 'Medications:', 'PMHx:', 'Investigations:', 'Plan:' etc.) (You MUST exclude '- ' from the note) History: (Present all symptoms and findings as direct statements without preceding verbs like 'reports' or 'complains of'. Use clear, concise language while maintaining clinical accuracy. Don't end sentences with a period) [Mention reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention duration, timing, location, quality, severity and/or context of complaint, if relevant and mentioned] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention how the patient describes their symptoms have changed or evolved over time, if mentioned] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [List anything that worsens or alleviates the symptoms] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Detail any mentioned past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Explain how the patient feels that the symptoms affect their daily life, work, and activities] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention the patient's own thoughts about the cause of their presenting complaints, any underlying concerns regarding the diagnosis and any stated expectations or hopes from the appointment e.g. receiving antibiotics or worried it may be cancer etc.] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention any past medical history or surgical history relevant to the presenting complaint] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention any relevant drug history/medications for the presenting complaint] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention any relevant family history for the presenting complaint] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Mention any relevant social history e.g. lives with, occupation, smoking/alcohol/drugs, recent travel, carers/package of care (if applicable)] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Summarise any relevant investigations discussed within the consultation (Provide a written summary only, for example say 'static inflammatory markers' or 'improving anaemia', don't say the exact results e.g. 'ALT 50')] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Examination: (If the consultation was a telephone call: you must completely exclude this 'Examination:' section from the note, including the heading. Do not explicitly state that this has been excluded or examination not performed.) [Mention chaperone information: if a chaperone was offered to the patient for this examination were they declined or accepted; role and name of chaperone if accepted] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Vital signs listed, eg. Temp , Sats %, HR , BP , RR , (as applicable)] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Physical or mental state examination findings, including system specific examination] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Comment (do not add subsections or subheadings. Write in present tense): [Likely diagnosis/diagnoses] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Differential diagnosis/diagnoses] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Investigations planned] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [If shared decision making occurs, list the multiple management options discussed with the patient and then patient's preference] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Treatment planned] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Relevant other actions such as advice, referrals etc] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Follow up plan] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) [Safety netting advice explicitly given in the consultation] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.)