Annual Diabetes Review:
Patient Information:
John Smith, DOB: 01/01/1960, Medical Record Number: 12345
Date of Review:
01 November 2024
Reason for Visit:
Annual review of diabetes management.
Medical History:
Type 2 diabetes diagnosed 10 years ago. No other significant medical conditions.
Medications:
Metformin 1000mg twice daily, Lisinopril 10mg daily.
Allergies:
No known allergies.
Lifestyle and Self-Management:
Patient reports a balanced diet, exercises 3 times a week, non-smoker, drinks alcohol occasionally.
Physical Examination:
Weight: 80kg, Height: 1.75m, BMI: 26.1, Blood Pressure: 130/80 mmHg.
Laboratory Results:
HbA1c: 7.2%, Fasting Blood Glucose: 140 mg/dL, Lipid Profile: within normal limits, Kidney Function Tests: normal.
Complications:
No current diabetes-related complications.
Foot Examination:
Normal skin condition, no ulcers.
Eye Examination:
No signs of retinopathy.
Management Plan:
Continue current medications. Encourage patient to maintain current lifestyle. Review HbA1c in 3 months. Refer to dietician for dietary advice.
Patient Education:
Provided education on importance of regular blood glucose monitoring and healthy eating.
Follow-Up:
Review in 3 months. Next HbA1c in 3 months.
Annual Diabetes Review:
Patient Information:
[include patient’s name, date of birth, and medical record number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Date of Review:
[include the date of the annual diabetes review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Reason for Visit:
[describe the reason for the annual diabetes review, including any specific concerns or symptoms mentioned by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medical History:
[document the patient’s medical history, including duration of diabetes, type of diabetes, and any other relevant medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications:
[list all current medications, including dosages and any over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies:
[mention any known allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Lifestyle and Self-Management:
[include information on the patient’s diet, exercise routine, smoking status, alcohol consumption, and any self-management practices] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physical Examination:
[document findings from the physical examination, including weight, height, BMI, blood pressure, and any other relevant observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Laboratory Results:
[include results from recent laboratory tests, such as HbA1c, fasting blood glucose, lipid profile, kidney function tests, and any other relevant tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Complications:
[document any diabetes-related complications, such as neuropathy, retinopathy, nephropathy, cardiovascular disease, and any other relevant complications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Foot Examination:
[include findings from the foot examination, such as skin condition, presence of ulcers, and any other relevant observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Eye Examination:
[document findings from the eye examination, including any signs of retinopathy or other eye conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Management Plan:
[outline the management plan, including any changes to medications, lifestyle recommendations, referrals to specialists, and follow-up appointments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Patient Education:
[include any education provided to the patient regarding diabetes management, lifestyle changes, and self-monitoring] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Follow-Up:
[document the recommended follow-up schedule, including the date of the next review and any interim appointments or tests] (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, depending on the format, as needed to capture all the relevant information from the transcript.)
