Peds Acute Visit

Subjective: [ Patient's name], [age in years or if less than 2 years old in months], [gender], accompanied by [name of family member if provided and relation to patient] for [ - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc. Write this out in detailed paragraph form. If multiple complaints group all information from one complaint prior to going onto next] [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention medications and herbal supplements] (list them one-by-one and include dose, frequency, etc for each) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) ROS: [list ROS with pertinent positives and negatives, if system isn't mentioned leave it out] Examination: - General: [describe general appearance, hygiene, body habitus, distress level, etc] - Head: [describe head examination findings] (if not mentioned state Normocephalic, atraumatic.) - Ears: [describe right ear examination findings] [describe left ear examination findings] (if not mentioned state External Ear grossly normal. No tenderness with movement.) - Eyes: [describe eye examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Nose: [describe nose examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Throat: [describe nose examination findings] (if not mentioned state, Moist mucous membranes. No tonsillar exudates or erythema.) - Lungs: [describe lung examination findings] (if not mentioned state: Respiratory effort comfortable, without use of accessory muscles. Vesicular breath sounds appreciated equally throughout lung fields. No wheezing, consolidation, or rhonchi appreciated.) - Cardiovascular: [describe cardiovascular examination findings] (if not mentioned state: Good perfusion. Brisk Capillary Refill. Auscultation of Regular Rate and Rhythm for age. No murmur appreciated upon auscultation.) - Gastrointestinal: [describe gastrointestinal examination findings] (if not mentioned leave blank.) (if general exam state: Soft, non-tender, non-distended. No organomegaly. Normoactive bowel sounds. ) - Musculoskeletal: [describe musculoskeletal examination findings] (if not mentioned leave blank.) (if general exam state: No joint swelling, erythema, or tenderness.) - Neurological: [describe neurological examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank ) (if asked for general exam state AOx3. CN II-XII grossly intact. Normal gait and coordination.) - Skin: [describe skin examination findings] (if not mentioned state ) (if asked for general exam state Warm and dry. No rashes or lesions. ) Impression and Plan: 1. [describe primary issue] - Impression: [describe impression of primary issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Differential diagnosis: [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Investigations planned: [list planned investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Treatment planned: [describe treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Prevention: [describe prevention strategies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Referrals: [list referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) 2. [describe secondary issue] - Impression: [describe impression of secondary issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Differential diagnosis: [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Investigations planned: [list planned investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Treatment planned: [describe treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Prevention: [describe prevention strategies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Referrals: [list referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) 3. [describe tertiary issue] - Impression: [describe impression of tertiary issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Differential diagnosis: [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Investigations planned: [list planned investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Treatment planned: [describe treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Prevention: [describe prevention strategies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Referrals: [list referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) ICD-10: [list ICD-10 codes] [list symptom ICD-10 code for any testing, then a final diagnosis as the topic] CPT: [list CPT codes; assume established patient unless stated as new to clinic or new patient] [ add any procedure codes described in visit][ list complexity or time justification for billing justification] (Make sure to ALWAYS bold the main headings in your output.) (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 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.)