ED Clinical Note

"Verbal consent was gained from [patient name] to use an AI scribe to record and document the consultation" [Patient Name] is a [describe patient’s age and gender using appropriate term based on age category] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.) Social: [Describe social history including information about smoking, alcohol, illicit drug use, work or study, living situation and conditions, use of mobility aids, and household members] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Presenting Complaint: [Describe the reason for the emergency visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in one or two full sentences.) Past Medical History: [Summarise past medical history including chronic conditions, resolved conditions, and previous surgeries] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.) History of Presenting Complaint: [Describe history of presenting illness including time of onset, speed of onset, duration, severity, associated symptoms, exacerbating and relieving factors] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in detailed paragraphs of full sentences.) Medication History: [List current medications including dosage and frequency where available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points, one per line.) Allergies: [List allergies including type of allergen and description of reaction] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points, one per line.) Family History: [Describe relevant family history including medical conditions, age of onset, severity, and relation to the patient where available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points, one per line.) ON EXAMINATION: _General:_ [Summarise general appearance and examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence format.) _Vitals:_ [Record vital signs such as blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points, one observation per line.) [Summarise system-specific exam findings including cardiovascular, respiratory, abdominal, neurological or others as applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Group findings by system heading where possible and write in bullet points.) Investigations currently available: - Bloods: [Summarise available blood test results including type of test and date] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - Imaging: [Summarise available imaging results including modality and date] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - Other: [Summarise any other investigation findings such as ECG or bedside tests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Assessment: - Primary Diagnosis: [State the primary diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own diagnosis.) - Differential Diagnosis: [List differential diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own differentials.) Plan: - Immediate Management: [Describe immediate management including treatments, procedures, and medications with doses if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own management plan.) - Investigations Planned: [List further investigations planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own investigations.) - Referrals: [List any specialty consultations or referrals requested] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own referrals.) - Discharge Criteria: [Describe conditions or criteria for discharge or admission] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own discharge plan.) - Follow-up: [List follow-up care instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own follow-up plans.) "This note was generated by an AI scribe and has been checked by me for accuracy. I am satisfied it is an accurate representation of the encounter." (Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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.)