Perfect GP Consultation Note

**Consult Summary:** [Two-line concise summary of entire consult starting with patient's presenting complaints and patient concerns, and brief management plan in key words. Avoid unnecessary wording, disregard formal grammar. Write in the style of a brief post-it note reminder for subsequent consultations.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Issues:** (Repeat the following issue structure for each distinct issue mentioned in the consultation.) **Issue 1: [Issue heading]** - [Brief description of the issue including timeline of symptoms and associated symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each.) - [Systems review with pertinent negatives or positives] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each.) - [Social history, medications, examination findings, past investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each.) - [Specialist or allied health review, differential diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each.) **Medications** - [List of medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write each on a new line.) **Past Medical History** - [List of past medical history items] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write each on a new line.) **Social History** - [List of relevant social history items including living arrangement, smoking history, alcohol intake, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write each on a new line.) **Preventative History** - [List of preventative health activities including cervical screening test, mammogram, prostate blood test, FOBT, BMD, vaccines] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write each on a new line.) - [Include any recent optometry review, skin check, or other preventative care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Physical Examination** - [Vitals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate on different bullet points.) - [Examination findings including signs and observations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate on different bullet points.) **Impression:** (Repeat the following issue structure for each distinct issue mentioned in the consultation.) - Issue 1: [Issue impression or diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include list of mentioned possible differential diagnoses.) **Plan:** - [Advice given] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each. Use medical abbreviations and acronyms, disregard formal grammar.) - [Actions required and rationale for tests if provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Separate into multiple bullet points no longer than 10 words each. Use medical abbreviations and acronyms, disregard formal grammar.) (Provide granular detail. Consolidate issues when closely related. Omit headings if not mentioned. Use UK English spelling and Australian AEST date/time. Use medical terminology where possible including commonplace GP abbreviations or acronyms. Be specific with mentioned medication names. Keep in mind that the transcript may be about a variety of topics, from medical conditions, to mental health and social concerns, to dietary and exercise discussions and you must always attempt to use the transcript to create a list of topics discussed using the template above. Use as many issues and bullet points as necessary to ensure clinical information is adequately organised for easy reading comprehension.)