S – Subjective (Patient History)
[Presenting concerns] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
[Menopausal status] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Pre-menopausal
[ ] Perimenopausal
[ ] Post-menopausal
[ ] Early menopause
[ ] Premature ovarian insufficiency
[Symptoms reported] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Hot flushes
[ ] Night sweats
[ ] Irregular periods
[ ] Vaginal dryness
[ ] Mood changes
[ ] Sleep disturbance
[ ] Cognitive symptoms
[ ] Libido changes
[ ] Weight changes
[Impact on daily life and wellbeing] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Medical history:
• [Chronic conditions] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
• [Surgical history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
• [Family history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points. Include breast cancer, osteoporosis, cardiovascular disease if mentioned.)
Reproductive history:
• [Age at menarche] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• [Parity] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• [Contraceptive history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Medication history and allergies:
• [Current medications] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
• [Allergies] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[Contraindications to treatment] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
O – Objective (Examination & Investigations)
Vital signs:
• [Blood pressure in mmHg] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• [Height in cm] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• [Weight in kg] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• [BMI] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Physical examination:
• [General examination findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
• [Gynaecological examination findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[Investigations initiated] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Cervical screening (if due)
[ ] Mammography referral
[ ] Bone densitometry (DXA)
[ ] Blood tests – FSH
[ ] Blood tests – Estradiol
[ ] Blood tests – TSH
[ ] Blood tests – Lipids
[ ] Blood tests – Vitamin D
[ ] Blood tests – Other
[ ] Pelvic ultrasound (if indicated)
[Referrals made] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Gynaecologist
[ ] Endocrinologist
[ ] Physiotherapist
[ ] Dietitian
[ ] Psychologist
[ ] Other
A – Assessment
"Menopause/perimenopause health assessment in accordance with MBS Item 695."
[Symptoms consistent with] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Perimenopause
[ ] Menopause
[ ] Premature ovarian insufficiency
[ ] Early menopause
P – Plan
Management discussion:
Non-pharmacological options:
[Non-pharmacological options discussed] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Lifestyle changes
[ ] CBT / psychological support
[ ] Vaginal moisturisers / lubricants
[ ] Sleep strategies
[ ] Stress management
Pharmacological options:
[Pharmacological options discussed] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] MHT / HRT (benefits and risks discussed)
[ ] Local estrogen therapy
[ ] Non-hormonal options (e.g. SSRIs, clonidine)
Patient-centred management plan:
• [Symptom management agreed] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
• [Follow-up arranged] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
• "Discussed shared decision-making"
[Preventative care advice] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Physical activity
[ ] Smoking cessation
[ ] Alcohol reduction
[ ] Weight management
[ ] Calcium/vitamin D intake
Health professional assistance (if applicable):
• [Assisted by] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
• [Under supervision of] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
• [Competency confirmed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a checkbox: mark with "[x]" if confirmed, "[ ]" if not.)
Eligibility check:
[Eligibility for MBS Item 695] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] No Item 695 claimed in last 12 months
[ ] Patient meets criteria
Billing:
MBS Item: "695 – Menopause/Perimenopause Assessment"
[Date of assessment] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single line.)
(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.)
