EMIS Consultation Record

Problem: [one or more concise clinical labels] (Include only if explicitly mentioned in the transcript, contextual notes or clinical note. Do not infer new diagnoses. Write as concise, SNOMED-friendly clinical phrases reflecting clinician- or patient-stated problems. Avoid unnecessary wording.) History: [relevant history of presenting problem] (Only include if explicitly mentioned or clearly supported by the transcript, contextual notes or clinical note. Write as a series of short statements, each on a new line. Allow light clinical normalisation of language (e.g. “pins and needles” → paraesthesia) without introducing new information. Include where present: onset, duration, progression, symptom character, key positives/negatives, functional impact, relevant past medical history, and current medications/adherence. Do not force subheadings—keep a logical, linear flow. Do not add new clinical interpretation.) Examination: [physical examination findings] (Only include if explicitly documented in the transcript, contextual notes or clinical note. Record findings exactly as stated. Write as concise factual statements, not prose. If none, state exactly: “No examination performed today.”) Family History: [relevant family medical history] (Only include if explicitly mentioned and relevant to the presenting problem, else omit section entirely. Record as stated without inference. Write in concise sentences.) Social: [relevant social history including occupation, lifestyle factors, social circumstances] (Only include if explicitly mentioned and relevant to clinical context, else omit section entirely. Record as stated without inference. Write in concise sentences.) Comment: [documented clinician plan, actions, advice and follow-up] (Include whenever a plan is explicitly stated in the transcript, contextual notes or clinical note. Do not generate or suggest new management plans. Format as numbered problems where possible. Record clinician-stated impression, actions (Rx/referral/tests), advice, and follow-up/safety-netting. Write each action on a new line without bullet points. Keep concise but clinically complete. Do not omit if a plan is documented.) Suggested SNOMED Codes: [codable clinical terms explicitly mentioned in the consultation] (Only include if directly stated in the transcript, contextual notes or clinical note, else omit section entirely. List as bullet points with concise EMIS-searchable phrases. This section is for clinician review only. Do not infer new diagnoses, symptoms, or findings. Avoid duplication and prioritise clearly documented items.)