**Grund des Besuchs:**
[Beschreibe den Hauptgrund für den heutigen Besuch, z. B. akute Beschwerden, Kontrolltermin oder Vorsorgeuntersuchung] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Diagnose:**
- [Arbeitsdiagnose oder Verdachtsdiagnose in prägnanter Form, inklusive passendem ICD-10-GM-Code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use only valid, standardised and officially recognised ICD-10-GM terms and codes. Do not invent or interpret diagnoses; only include ICD-10-GM codes if a diagnosis is clearly named.)
- [Differenzialdiagnosen mit kurzer klinischer Begründung und zugehörigem ICD-10-GM-Code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use only valid, standardised and officially recognised ICD-10-GM terms and codes. Do not invent or interpret differential diagnoses; only include ICD-10-GM codes if clearly named.)
**Anamnese:** (Structure as narrative text with subheadings if present)
- [Symptombeschreibung inkl. Dauer, Intensität, Verlauf, begleitende Beschwerden sowie was Symptome verschlimmert oder lindert – inklusive Selbstbehandlung, falls erwähnt] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medikamentenanamnese inkl. aktueller Dauermedikation, Bedarfsmedikation, Dosierung, Einnahmeschema, sowie Einnahmetreue und eventuelle Probleme] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergien inkl. Art des Allergens, Reaktionsmuster, Schweregrad und letzter bekannter Kontakt] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Familienanamnese mit relevanten Erkrankungen bei erstgradigen Angehörigen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Sozialanamnese mit Angaben zu Beruf, psychosozialer Belastung, Wohnsituation, Bewegung, Alkohol- und Nikotinkonsum – nur relevante Inhalte erfassen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Vorerkrankungen oder frühere Operationen mit Relevanz für den aktuellen Besuch – inkl. Jahr/Zeitraum falls verfügbar] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Körperliche Untersuchung / Befunde:** (Structure as narrative text with subheadings if present)
- [Befunde der körperlichen Untersuchung, inkl. relevante Vitalparameter, Sicht-, Tast-, Hör- oder Funktionsbefunde] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Labor- oder apparative Diagnostik, inkl. durchgeführte Tests und relevante Ergebnisse, z. B. Blutbild, EKG, Urinstatus] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If apparatus-based investigations like MRT, CT, Sonographie or Röntgen are mentioned, create a bold heading for each and present findings in a separate section. If clinical examination findings are mentioned, structure them under: Stand und Gangbild, Untersuchung im Sitzen, Neurologie, Durchblutung und Trophik.)
**Therapie / Maßnahmen:**
- [Medikation inkl. Name, Wirkstoff, Dosierung, Einnahmeschema, Therapiedauer, ggf. Therapieziel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Weitere Maßnahmen wie physikalische Therapie, Ernährungsberatung, Verhaltensempfehlungen oder Krankschreibung] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Überweisungen an Fachärzt:innen, Einweisungen oder empfohlene Weiterdiagnostik, inkl. Grund der Überweisung] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Empfehlungen:**
- [Empfohlene Verlaufskontrolle mit Zeitangabe und Ziel der Kontrolle] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Wiedervorstellung inkl. Zeitrahmen oder Symptombeobachtung, die zur erneuten Vorstellung führen sollte] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Aufklärung über Diagnose, Therapie, Risiken oder Hinweise zur Selbstbeobachtung] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never invent or interpret patient details, diagnoses, assessments, plans, interventions, evaluations, or next steps. Use only the transcript, contextual notes, or clinical note as reference. If any placeholder has not been explicitly mentioned, do not state this in the output; simply leave the section out. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)
