GP notes

History - [describe presenting complaint, history of presenting complaint, reason for visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) try keep this as concise as possible. Include important negatives and positives. - [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention patient's concerns, ideas or expectations here] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [document each problem separately if there are multiple issues in a single consultation] Examination: (For the examination - write O/E: instead of examination) Temperature ( abbreviate to T), Heart rate (abbreviate to HR), Respiratory rate (abbreviate to RR), Oxygen saturations ( abbreviate to sats) Put all the vital signs on one line Impression [clinical impression or differential diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: [treatment plan, including medications, therapies, and follow-up appointments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [patient education and counselling] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [referrals to specialists or other healthcare providers] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [additional tests or investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave [safety netting advice given] (include any specific advice and when or how to seek help) (if advised to seek medical attention - specify this is to call back/call 111/999/go to A&E) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, 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.)