[Names and relationship to patient of other people in attendance at appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
History:
[Issue, problem or request 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points per issue.)
- [History of presenting complaint or request 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Associated symptoms with issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Relevant negative symptoms for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Issue, problem or request 2] (Repeat this format for each additional issue raised. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [History of presenting complaint or request 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Associated symptoms with issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Relevant negative symptoms for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Issue, problem or request 3, 4, 5 etc] (Repeat as needed. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [History of presenting complaint or request 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Associated symptoms with issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Relevant negative symptoms for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Past Medical History:
[Relevant medical, surgical, family, medication, social history, or allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points if more than one item is listed.)
Other:
[Personal context such as social updates, holidays, or non-medical topics discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
Physical Examination:
[Vital signs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Physical or mental state examination findings, including system-specific exams] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Impression and Plan:
1. [Issue, problem or request 1 – summarised as condition or concern name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Likely diagnosis or impression for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Differential diagnosis for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Investigations planned for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Treatment planned for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Referrals or follow-up actions for issue 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
2. [Issue, problem or request 2 – summarised as condition or concern name] (Repeat format for each subsequent issue. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Likely diagnosis or impression for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Differential diagnosis for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Investigations planned for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Treatment planned for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Referrals or follow-up actions for issue 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
3. [Issue, problem or request 3, 4, 5 etc – summarised as condition or concern name] (Repeat as needed. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Likely diagnosis or impression for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Differential diagnosis for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Investigations planned for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Treatment planned for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Referrals or follow-up actions for issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, contextual notes 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 to include 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.)
