eCCR Discharge Summary

[patient's age and gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) " presenting with: " [reason for presentation including symptoms and duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) # [list of known medical conditions or diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) # [additional known medical conditions or diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Vitals on arrival: " [vital signs including temperature, heart rate, blood pressure, respiratory rate, oxygen saturation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "General examination: " [findings of general physical examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Cardiovascular: " [findings of cardiovascular examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Respiratory: " [findings of respiratory examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Abdominal: " [findings of abdominal examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Neurological: " [findings of neurological examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Admitted " [admission status, ward, or unit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) " for " [reason for admission] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Assessment: " [clinical assessment of the patient's condition, differential diagnoses, and contributing factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Management: " [treatment plan including investigations, medications, procedures, and referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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.)