Scribe BC - ED General Note

**ID:** - [Patient name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) is a [Patient's age (only if mentioned in transcript or patient details, otherwise omit completely)] [Patient gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **CC:** - [Chief complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **HPI:** - [Describe history of presenting illness, including onset, duration, and characteristics of symptoms, pertinent positives and pertinent negatives] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **PMHX:** (include this PMHX section in the output if past medical history information has been explicitly mentioned in the transcript or contextual notes, even if there is "none" or "no past medical history" stated, otherwise remove the PMHX section from the output) - [Describe past medical history, including previous surgeries, that are mentioned either in the transcript or the context section. If I state EXPLICITLY that there is no past medical history then output: "none" for this section) **MEDS:** (only include this MEDS section in the output if medications have been explicitly mentioned in the transcript or contextual notes, otherwise remove the MEDS section from the output) - [Mention current medications and herbal supplements, that are mentioned either in the transcript or the context section. If I state EXPLICITLY that there are no medications, then output: "none" for this section) **ALLERGIES:**(only include this allergies section in the output if allergies have been explicitly mentioned in the transcript or contextual notes, otherwise remove the ALLERGIES section from the output) - [Mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, include "NKDA" if explicitly "none" is stated, otherwise leave entire section blank.) **FAMILY HISTORY:** (only include this Family history section in the output if family history information has been explicitly mentioned in the transcript or contextual notes, otherwise remove the FAMILY HISTORY section from the output) - [Family history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **SOCIAL HX:** (only include social history section in the output if social history information has been explicitly mentioned in the transcript or contextual notes, otherwise remove the SOCIAL HX section from the output) - [Describe social history, including smoking, alcohol use, and occupation, parental custody issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave entire section blank) **PHYSICAL EXAM:** (only include this general section in the output if general exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the General appearance section from the output, do not double space this section) [Vital signs] (only include this vital signs section in the output if any vital signs have been explicitly mentioned in the transcript or contextual notes, otherwise remove the vital signs section from the output) [General appearance findings, not mentioned anywhere else below] (only include this vital signs section in the output if any vital signs have been explicitly mentioned in the transcript or contextual notes, otherwise remove the vital signs section from the output) [Vital signs] (only include this HEENT section in the output if head, eyes, ears, nose, or throat exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the HEENT section from the output) [HEENT: Head, eyes, ears, nose, throat examination findings] (only include this Neck section in the output if neck examination findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the Neck section from the output) [Neck examination findings] (only include this CVS section in the output if cardiovascular findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the CVS section from the output) [CVS: cardiovascular examination findings] (If “normal heart sounds” or "cardiac exam normal" or “normal cardiac exam” is stated, then you must output the following: "CVS: normal S1 / S2, no S3/S4 or murmurs") (only include if mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and omit header.) (only include this Resp section in the output if respiratory exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the Resp section from the output) [respiratory examination findings] (only if "normal lungs" or "resp exam normal" or "normal respiratory exam" is stated then you must output, "Resp: chest clear to auscultation, no crackles / wheezes, no crepitus", otherwise do not include) (only include if mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and omit header.) (only include this Abdomen section in the output if abdomen exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the abdomen appearance section from the output) [Abdomen: abdomen examination findings] (only if "normal abdomen" is stated then you must output, "Abdomen: soft, non-tender, no peritonitis or guarding, no masses", otherwise do not include) (only include if mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and omit header.) (only include this extremities section in the output if extremity exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the extremities section from the output) [Extremities examination findings] (only include this Back section in the output if Back exam findings have been explicitly mentioned in the transcript or contextual notes, otherwise remove the Back section from the output) [Back exam (ASIA scale): General: Tenderness to palpation to: [area of tenderness] Bruising: [none] Scars: [none] **RESUSCITATION:** [insert resusctiation start and end time stated] [Summarize resuscitation, primary survey, and initial resuscitative management of the patient in story form with detail. After resuscitation closed put rest of detail in HPI} (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Do not include section above if not mentioned.) **INVESTIGATIONS:** - [List investigations ordered and results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **REASSESSMENT:** Reassessment at [time of reassessment] due to change in condition / treatment plan (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.). Re-examined: [area, region, or region of patient that was examined]. [describe findings from the re-examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Plan changed: [describe the changes in the treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (write this whole section as a narrative and never use bullet points) **PROCEDURE NOTE:** (only include this Procedure note section in the output if procedures information has been explicitly mentioned in the transcript or contextual notes, otherwise remove the PROCEDURE NOTE section from the output) - [Describe procedure] (Do not include section above if not mentioned.) **IMPRESSION / PLAN:** (DO NOT INCLUDE any previous diagnosis or treatment plans that are only mentioned in the context section and NOT in the transcript. The context section does not indicate present day impressions, diagnosis, or Treatment plans - [Impression: Medications with doses, Procedures etc (only include if explicitly mentioned), including working diagnosis and differential diagnoses mentioned] (use medical jargon, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Plan: Treatment and follow-up instructions (enumerated, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Referrals: Specialty consultations (only include if explicitly mentioned)] - [Discharge Criteria: Conditions for discharge or admission (only include if explicitly mentioned)] - [Reasons to return to the emergency department: Instructions for reasons to return to the emergency department (only include if explicitly mentioned)] “The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.” (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 include 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 omit the placeholder completely if not mentioned.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information) (always bold section headings, this is very important)