Scribe BC - ICU Consult

Scribe BC - ICU Consult **Time seen**: [time of consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Identifying factors**: [Age, sex, occupation],[include how transported to the hospital], (EHS means emergency health services), [include who referred for icu consult] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **History of present illness**: [include EHS, paramedic and fire personnel reports], [include course in hospital] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use grammatically correct full sentences only, the subject of the sentence is "the patient" or his name, no phrases, no partial sentences. Do not use the patient's name and use pronoun only.) **Pre-admission medical history**: [include chronic medical problems, chronic diseases, include obesity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Put in bullet form. Put conditions patient does not have when explicitly mentioned and make it clear. Number them in list form. Use bullet points.) **Past surgical history**: [include procedures in the past] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Put in bullet form.) **Medications prior to admission**: [list medications taken before hospital admission] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Put in bullet form.) **Current medications in hospital**: [list current hospital medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Put in bullet form.) **Allergies**: [list known allergies and reactions] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Social History**: [family members, spouse, common law, partners, friends] (include all occupations, employments, jobs, work, and profession) (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Family history**: [diseases that family members had] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Code status**: [code status details] (include MOST, code status can only be CPRC2, DNACPRM3, DNACPRM1, DNACPRC2) (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Substance use**: [smoking, alcohol, substance abuse, street drugs] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Physical exam**: **General appearance/head and neck exam**: [general appearance, temperature] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **CNS**: [level of consciousness, oriented, alertness, motor strength, limb movement, pupils] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Prop means propofol and infusion units are mg/kg/min iv, fent means fentanyl and iv infusion units are mcg/hr, precedex infusion rates are mcg/kg/hr.) **CVS**: [blood pressure and heart rate and rhythm, jvp, pulses, mottling, duskiness, cap refill, edema] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Levo means levophed and units are mcg/min iv. Include iv vasoactive medications such as epinephrine (mcg/min), norepinephrine, milrinone, labetolol iv, hydralazine iv.) **Resp**: [respiratory examination findings and ventilatory support] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include details regarding mechanical ventilation, High flow means high flow nasal cannula and abbreviate as HFNC.) **GI**: [include ng or og or peg tube or tpn] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **GU**: [include fluid balance and maintenance iv] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Skin**: [skin examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Labs**: [laboratory results organized by category] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Put hemoglobin, white cell count, platelet count on one line, put sodium, potassium, bicarbonate, chloride and creatinine on another line, put all other labs on another line. Include previous and old lab values.) **Previous labs**: [previous laboratory values] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Imaging**: [imaging results and findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **ID and micro**: [infection, microbiology results, and antibiotic information] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Active Issues**: [include active problems] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.) **Management plan**: [detailed management plan with rationales] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include names of antibiotics and indication for use. Give reasons for plan. Use bullet points.) **Consultants**: [add name, specialty, and recommendations by other doctors, specialists] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Addendum**: [additional notes or updates] (Only include if explicitly mentioned in transcript or context, else omit section entirely) **Critical Care**: [critical care specific assessments and plans] (Only include if explicitly mentioned in transcript or context, else omit section entirely) "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks." (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.)