GP Document Template

Presenting Problem(s) [describe current and ongoing health issues, including specific complaints, measurements, current strategies being employed to address these issues, and patient-stated goals or targets] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) Past Medical History [document relevant past medical conditions, diagnoses, and any resolved health issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) Current Medications & Allergies [list all current medications including dosage, frequency, and route, and document any known allergies or sensitivities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) Examination [record objective findings from physical examination, including relevant measurements or observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) Impression [summarize the clinical assessment, including diagnoses, differential diagnoses, or the main problem list requiring intervention, and any contributing factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) Plan [detail the comprehensive management strategy for each identified problem or impression, including initiated treatments, prescribed medications, dosage, duration, potential side effects, and storage instructions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) [outline any referrals to other healthcare providers, including their names, practice locations, and number of allocated sessions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) [document follow-up plans, including scheduled review dates, type of review (e.g., in-person, telehealth), and any pending results or communications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with bullet points for sub-items.) (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.)