Dr Babar's Template

Presenting Complaint: [details of the patient’s presenting issue, including main symptoms and concerns] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write in a single paragraph.) History of Presenting Complaint: [description of onset, duration, location, character, severity and progression of the issue] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write in full sentences.) [details of pain] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write in full sentences.) [concerns, ideas, and expectations of the patient] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.) [previous episodes of similar condition] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.) [medications used including any self-treatment or previous prescriptions] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.) [living and working conditions relevant to the presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write in full sentences.) Examination Findings: [consent and explanation provided for examination] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.) [temperature recorded] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write on the same line.) [pulse rate recorded] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write on the same line.) [blood pressure measurement] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write on the same line.) [back examination findings] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) [neurological and vascular examination findings] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) [results of any special tests performed] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) Diagnosis: [state the diagnosis based on history and examination] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write in a sentence.) Management Plan: [patient education topics covered] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) [reassurance provided and educational messages given] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) [non-pharmacological strategies discussed, such as rest, exercise, heat/cold therapy etc.] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) [medications prescribed or adjusted] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as bullet points.) Safety Netting: [advice provided for red flags, when to seek medical attention, or worsening symptoms] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a paragraph.) Review: [timeframe for follow-up or review] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write on a single line.) (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. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)