Reforme Consultation

(Throughout the document, never use the patient's name. Instead, use the word "Patient" when it starts a sentence and "patient" in lowercase otherwise.) (Write each complete sentence on a separate line.) (Always write in UK English spelling.) (Only include information if explicitly mentioned in the transcript, contextual notes, or clinical note unless otherwise instructed.) (Do not infer or invent clinical details.) Patient Details [Patient's sex and occupation or educational status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a full sentence on its own line.) [Permission for GP contact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a full sentence on its own line.) [Consent for use of anonymised photos for educational purposes] (Always include. If not explicitly mentioned, write exactly: "Consent for use of anonymised photos for educational purposes not discussed." Write as a full sentence on its own line.) Source Of Inquiry [Document the source of the patient's inquiry] (Always include this section. If not explicitly mentioned, leave blank after the heading. If mentioned, write as a full sentence on its own line.) Refer to Medical Questionnaire and Treatment Questionnaire in Patient Folder for medical history. Chaperone [Document whether chaperone was present or available at examination and treatment] (Always include. If not mentioned in the transcript, contextual notes or clinical note, write exactly: "Chaperone present or available at patient's request." Write as a full sentence on its own line.) Patient Requesting Medical Advice About [Describe the specific medical advice requested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each sentence on a new line.) Allergy History [Document allergy history including medication, latex, anaesthetic or other allergies OR confirm absence] (If allergies are explicitly mentioned, document details. If no allergies to Azithromycin, Lorazepam, Adrenaline, Lignocaine or Latex are mentioned, write exactly: "No allergies reported to Azithromycin, Lorazepam, Adrenaline, Lignocaine, Latex." If no adverse effects from past local anaesthetic injections are mentioned, write exactly: "No adverse effects to past local anaesthetic injections reported." Write each sentence on a new line.) Medical History [Document relevant past medical history including nicotine exposure and recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. If no nicotine exposure is mentioned, write: "Patient is not exposed actively or passively to nicotine." If nicotine exposure is mentioned, document details and write: "Advice regarding risks of Nicotine exposure and need for abstinence for 4 weeks before and after treatment given." If no recreational drug use is mentioned, write: "Patient is not using recreational drugs." Write each sentence on a new line.) Past Treatment History [Document relevant past treatment history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each sentence on a new line.) Ongoing Medications [Document ongoing medications OR confirm none AND confirm safety screening statements] (Always include. If no medications are mentioned, write exactly: "No ongoing medications." If medications are mentioned, list each medication with name, form, dose, frequency and duration on a new line. If no inability to lie flat for 2 hours is mentioned, write exactly: "No history of being unable to lie flat for 2 hours." If no operations or diagnosed hernias in the treatment area are mentioned, write exactly: "No history of operations or diagnosed hernias in the treatment area." If no implants in treatment area or vicinity are mentioned, write exactly: "No Implant in treatment area or vicinity (eg pacemaker, internal defibrillator, hip or bone implants)." If no thrombophlebitis, clots, DVT or PE are mentioned, write exactly: "No history of thrombophlebitis, clots, DVT, PE." If no liver disorders or Cytochrome 450 deficiency are mentioned, write exactly: "No history of liver disorders or Cytochrome 450 deficiency." Write each sentence on a new line.) Drug Interactions With Medications To Be Used For Surgery [Document identified mild to moderate drug interactions OR omit] (Only include if patient is on medication and interactions are explicitly mentioned in the transcript, contextual notes or clinical note. Write each interaction as a separate sentence on a new line.) Absolute And Relative Contraindications Of Treatment [Document contraindications screening including keloidal scarring, pregnancy, body dysmorphic disorder, bleeding risk, infections and skin conditions] (If no keloidal scarring is mentioned, write exactly: "No history of keloidal scarring." If no ongoing pregnancy or breastfeeding is mentioned, write exactly: "No ongoing history of Pregnancy / Breastfeeding." If no suspicion of body dysmorphic disorder is mentioned, write exactly: "Body dysmorphic disorder not suspected." If no use of blood thinners, supplements increasing bleeding, high potency fish oils or aspirin is mentioned, write exactly: "No history of consumption of blood thinners or supplements that increase bleeding, high potency fish oils, aspirin." If no dental, urinary or skin infections are mentioned, write exactly: "No ongoing infections including dental infections, urinary infections, skin infections." If no active acne, inflammatory lesions or infections in treatment area are mentioned, write exactly: "No active acne, inflammatory lesions, infections in treatment area." If no active cold sores (herpes labialis), eczema or psoriasis in treatment area are mentioned, write exactly: "No active cold sores (herpes labialis), eczema or psoriasis in treatment area." If positive findings are mentioned, document details instead. Write each sentence on a new line.) Psychological Questionnaire Score "Psychological questionnaire score is designed for evaluating the psychological impact of the presenting problem and treatment desired and to document the patient's score on the psychological questionnaire section of the medical questionnaire and the reasons for seeking treatment." Patient Scores [Document patient's psychological questionnaire score] (Only include if explicitly mentioned. If score is 0, write that patient is seeking treatment for purely cosmetic reasons not related to mental or social health. Write as a full sentence on a new line.) Expectations From Treatment [Document patient's expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each sentence on a new line.) Does Patient Need Caprini Score Assessment [Document whether Caprini score assessment is required] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a full sentence on a new line.) Patient Evaluation HEIGHT (cms): [document patient's height in cms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) WEIGHT (kg): [document patient's weight in kg] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) BMI [document patient's BMI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) PR: [document patient's pulse rate] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) BP: [document patient's blood pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) SAT (ON AIR): [document patient's oxygen saturation on air] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) On Examination [Document physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write each finding as a separate sentence on a new line.) Medical Impression / Diagnosis [Document medical impression or diagnosis] (Only include if explicitly mentioned. Do not invent or infer a diagnosis. Write each diagnosis on a new line.) Icd Codes Applicable (International Classification Of Diseases For Mortality And Morbidity Statistics, 11th Revision, v2023-01) [document all applicable ICD codes for the patient's condition based on the entirety of the transcript, contextual notes, and clinical note] (Only include if applicable ICD codes can be derived from the transcript, contextual notes, or clinical note; otherwise, omit the section entirely. List as bullet points. Be comprehensive and include codes for all mentioned diagnoses, conditions, relevant history, and risk factors such as hypertension, allergies, BMI status, smoking history, medications, and psychological factors. Specifically check for and include any of the following common codes if relevant: EJ20.0 (Solar Elastosis), EE40 (Atrophy of connective tissue), EJ20 (Photoaging), H02.83 (Dermatochalasis), LA52 (Facial asymmetry), EE41 (Abnormalities of dermal elastin), L90.0 (Atrophy of skin), EE40.31 (Age-related skin fragility), 9A06.6 (Sunken Sulcus Deformity), 9A06.5 (Tear Trough Deformity), FC00.0 (Acquired deformity of nose), EL70 (Adverse reaction to dermal fillers), MB28.9 (Low self-esteem), R45 (Unhappiness), Z41.1 (Plastic surgery for unacceptable cosmetic appearance), F45.22 (Body dysmorphic disorder), EF02.3 (Cellulite), EF02.2 (Lipoedema), 5B81 (Obesity), L98.7 (Excessive and redundant skin), E65 (Localized adiposity), N62 (Gynaecomastia), Z79.51-Z79.52 (Long-term use of steroids), Z79.818 (Long-term use of agents affecting oestrogen levels), EE00.0 (Localised hyperhidrosis), EE00.00 (Palmar/plantar hyperhidrosis), EE00.01 (Axillary hyperhidrosis), D17.9 (Benign lipomatous neoplasm), L91.8 (Skin tags), D22 (Moles), L64.9 (Androgenic alopecia), ED70.1 (Female pattern hair loss), H02.4 (Ptosis of eyelid), H02.6 (Xanthelasma of eyelid), N90.69 (Hypertrophy of labia), I83.9 (Varicose veins), L91.0 (Hypertrophic scar/Keloid), Q17.5 (Prominent Ear).) Treatment Options Discussed Option 1: [document the option of not having treatment] (always include even when not mentioned explicitly in transcript, contextual notes or clinical note. Write on a single line.) Option 2: [document the details of the second treatment option discussed, including how it addresses the patient's problem and improves self-confidence and self-esteem] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list, with each sentence or distinct point on a new line.) Informed Consent [Document informed consent confirmation statements] (Always include. Write each of the following as separate sentences on new lines: Patient was taken through suitable treatment options including not having treatment. Patient was explained the treatment process, pros and cons and pre/post care requirements. Case studies with before and after photos were used for illustration. Patient understands photos are for illustration only and do not guarantee results. All patient questions were answered satisfactorily. Patient was given relevant treatment introduction, consent and pre/after care forms. Patient will follow up for a second consultation after considering information. Patient was warned about limitations of medical and surgical treatments and inability to guarantee results. Patient was informed about 10 - 20% reported patient dissatisfaction rates in cosmetic surgery.) Treatment Plan [Document treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each point on a new line.)