Epilepsy Consultation (Inpatient-first visit)

ADMISSION NOTE The patient was informed that an AI-assisted scribe was used for documentation purposes, and consent was obtained. Date: [Insert date and day] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Patient name and DOB: [Insert full name and date of birth in numerical format] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) ICD-10 code: [Insert appropriate ICD-10 code for South Africa] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Patient Summary: [Insert patient summary as age and sex of patient, type of epilepsy with aetiology if known, and reason for visit] (Only include if explicitly mentioned in the transcript or contextual notes. Do not generate or infer this information. Do not place a summary at the end of the note.) Current anti-seizure medications: 1. [Insert anti-seizure medication] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) 2. [Insert anti-seizure medication] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Previous anti-seizure medications: 1. [Insert previous anti-seizure medication and reason for discontinuation if mentioned] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Risk factors for epilepsy: [Insert relevant risk factors including birth history, developmental milestones, family history of epilepsy, head trauma, febrile seizures, meningitis or encephalitis] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) History of epilepsy illness: [Summarise epilepsy history including age of onset, medications tried, and seizure types] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Aura: [Insert aura description] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Ictus: [Insert ictal description] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Post-ictal: [Insert post-ictal features] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Duration: [Insert seizure duration] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Frequency: [Insert seizure frequency] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Previous investigations: 1. [Insert investigation type (e.g. MRI brain, EEG) with date in brackets and result] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Past medical/surgical history: - [Insert comorbidity or surgical history with associated medications] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Allergies: [Insert allergies] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Social history: [Insert occupation, living situation, alcohol use, recreational drug use, and smoking history] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Physical exam: [Insert physical examination findings] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Plan: 1. [Insert plan item discussed with the patient] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) 2. [Insert plan item discussed with the patient] (Only include if explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) (Never include direct quotations. Never generate or infer patient details, diagnoses, assessments, plans, or summaries. Use only the transcript or contextual notes as the source of information. If information related to a placeholder was not explicitly mentioned, omit the placeholder or section entirely. Do not add a patient summary at the end of the note.)