Scribe BC- BCCH Progress note

Patient Name: [Insert Name](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Birth: [Insert date of birth](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PHN: [Insert provincial health number](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Referring Provider: [Insert referring physician](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Location: [specify if Emergency Room; Medical ward; Infant Psychiatry Clinic, Outpatient Psychiatry Clinic; or RICHER Social Pediatrics Outreach Clinic](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PSYCHIATRY PROGRESS NOTE I saw [Insert Full Name] [in-person] for a follow-up appointment on [Insert Date] from [Insert appointment time slot]. [Mention if caregiver present or not]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) IDENTIFYING DATA: (copy from previous note if information remains current) [Insert Full name] is a [Insert age and gender] who lives with [insert living situation if reported]. [Insert first name] attends [insert school and grade and frequency of attendance]. Previous psychiatric diagnoses include [insert previous diagnoses]. [Insert First name] continues to attend [] and is followed through this clinic [as well as] [mention other healthcare providers supporting client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Insert relevant members of supports in community including care providers listed in previous notes in context) CURRENT MEDICATIONS: [List all current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. List each new medicine on a new line and use bullet points) INTERIM HISTORY (provide in paragraph format, no bullet points) [Mention reasons for visit, chief complaints such as requests, symptoms etc] [Mention Duration/timing/location/quality/severity/context of complaint] [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] [Progression: Mention describe how the symptoms have changed or evolved over time] [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) MENTAL STATUS EXAMINATION (if patient not present, omit. provide in paragraph format, no bullet points) [Record the patient's physical apperance and self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include emotional response if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include thought process and content if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [If reported, Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient. If none note "no observed perceptual disturbances"] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension and specify "however, not formally assessed".] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) PHYSICAL EXAMINATION (provide in paragraph format, no bullet points) [Physical examination findings including vital signs and system-specific examinations] (Only include if physical examination was explicitly mentioned as being performed in the transcript, contextual notes or clinical note; otherwise omit section entirely.) IMPRESSION (provide in paragraph format, no bullet points) [Mention likely diagnosis and change in status or stability since last visit] [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) PLAN (point form with no bullet points, utilize previous consultation recommendations if discussed) [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Treatment planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Relevant other actions such as counselling, referrals etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Next appointment date for psychiatric follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Mention it was a pleasure meeting with [First name] and [insert caregiver present first name] today.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Provider Name] Child and Adolescent Psychiatrist Psychiatry "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)