GP Consultation Note Template
"Patient has been consented to use AI scribe."
F2F:
Right knee pain
Seen with Daughter
Presenting Complaint and History:
68y/o female c/o R knee pain x 3/12. Gradual onset, worse with walking/stairs. No specific injury. Pain 6/10, aching. Stiffness in AM for ~15 mins. Denies swelling, redness, fever. No hx trauma. Self-medicating with OTC paracetamol, mild relief.
Risk Factors:
Obesity (BMI 32), sedentary lifestyle, family hx OA.
ICE:
Ideas: thinks it's 'wear and tear' due to age.
Concerns: worried about needing surgery, limited mobility impacting independence.
Expectations: wants pain relief, something to stop it getting worse.
Alcohol and smoking history:
Alcohol: 10 units/week. Occasional binge drinking.
Smoking: Ex-smoker, quit 5 years ago (previously 20/day x 40 yrs).
Allergy:
NKDA
Red Flags:
None identified (no night pain, weight loss, fever, constitutional symptoms).
Negative Symptoms:
No numbness, tingling, weakness in leg. No locking or giving way.
Examinations and Vitals Signs:
Obs: BP 130/80, HR 78, Temp 36.8C, SpO2 98% RA. BMI 32.
R knee: Mild crepitus on movement. Full ROM, slight pain at end range flexion. No effusion, warmth, or erythema. Good patellar tracking. Stable MCL/LCL. No meniscal signs.
Working Diagnosis:
Primary: Osteoarthritis, right knee.
Differentials: Meniscal injury, Patellofemoral pain syndrome.
Share Management Plan:
1. Medication: Paracetamol 1g QDS PRN, topical NSAID gel (e.g., Voltarol Emulgel) TDS for 2/52.
2. Investigation: X-ray R knee (AP/Lateral/Skyline views) to assess OA severity.
3. Follow up: Review in 4 weeks with X-ray results. Discuss physiotherapy referral if pain persists.
4. Referral: None at present.
5. Reassurance: Explained OA is common, management focuses on pain control & improving function. Not all cases require surgery.
Safety Netting Advice:
Advised to return if pain significantly worsens, develops swelling/redness, fever, or new neurological symptoms (numbness, weakness). Continue gentle exercise (walking, swimming) within pain limits. Weight loss encouraged.
**GP Consultation Note Template**
"(Write in concise bullet points. Use abbreviations and short phrases where possible. Avoid full sentences and unnecessary words. Organise all events chronologically by time and events.)"
"Patient has been consented to use AI scribe."
F2F:
[Main complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise and use abbreviations where appropriate.)
Seen with [Relationship of accompanying person] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not include names.)
Presenting Complaint and History:
[Detailed description of presenting complaint and relevant history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases and abbreviations.)
Risk Factors:
[Relevant risk factors identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
ICE:
[Patient's ideas about their condition] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be very concise.)
[Patient's concerns about their condition] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be very concise.)
[Patient's expectations regarding treatment or outcome] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be very concise.)
Alcohol and smoking history:
[Alcohol consumption details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise.)
[Smoking history details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise.)
Allergy:
[Medication allergy status] (If any medication allergies are mentioned in transcript, contextual notes, or clinical note, list them. If it is explicitly stated that the patient has no known drug allergies, state "NKDA". Otherwise, omit section entirely.)
Red Flags:
[Any red flag symptoms or findings identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise.)
Negative Symptoms:
[Any relevant negative symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise.)
Examinations and Vitals Signs:
[Summary of examination findings and vital signs] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
[Chaperone presence and details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise.)
Working Diagnosis:
[Differential diagnoses or working diagnoses considered by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Be concise and use "Primary" and "Differentials" as labels. Do not invent or infer a diagnosis.)
Share Management Plan:
1. Medication: [Medication details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases and standard abbreviations for frequency.)
2. Investigation: [Investigation details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
3. Follow up: [Follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
4. Referral: [Referral details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
5. Reassurance: [Reassurance provided] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases.)
Safety Netting Advice:
[Safety netting advice provided to the patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use concise phrases and abbreviations.)