**ID:**
- John Smith, 32-year-old male
**CC:**
- Suicidal ideation
**HPI:**
- The patient presents to the emergency department with suicidal ideation. He reports feeling overwhelmed by work stress and relationship problems. He denies any current plans or intent to harm himself but admits to passive suicidal thoughts. He reports feeling down for the past week. He denies any substance use. Reports no previous psychiatric history.
**PMHX:**
- none
**MEDS:**
- none
**ALLERGIES:**
- NKDA
**FAMILY HISTORY:**
- Father with history of depression.
**SOCIAL HX:**
- Smokes 10 cigarettes per day. Drinks alcohol socially.
**PHYSICAL EXAM:**
- General appearance: Appears stated age, well-groomed.
- Vital signs: BP 130/80, HR 88, RR 16, SpO2 98% on room air, Temp 37.0 C
- Mental Status Examination:
- Appearance: Well-groomed, appropriate for age.
- Behaviour: Cooperative and calm.
- Speech: Normal rate and rhythm, clear and coherent.
- Mood: Reports feeling down.
- Affect: Appropriate and congruent.
- Thoughts: No active suicidal ideation or homicidal ideation. No current plan or intent. Denies any command hallucinations.
- Perceptions: No hallucinations.
- Cognition: Oriented to person, place, and time. Intact memory and concentration.
- Insight: Aware of his current emotional state.
- Judgment: Good.
**INVESTIGATIONS:**
- CBC, CMP, UA ordered and pending.
**IMPRESSION / PLAN:**
- Impression: Major Depressive Disorder, rule out suicidal ideation.
- Plan:
1. Administer the Columbia-Suicide Severity Rating Scale (C-SSRS).
2. Initiate a psychiatric consultation.
3. Discussed safety plan with the patient.
4. Patient to be placed on 1:1 observation.
5. Patient to be admitted to the psychiatric unit for further evaluation and treatment.
- Referrals: Psychiatric consultation completed.
- Discharge Criteria: Patient will be discharged when suicidal ideation resolves and a safe discharge plan is in place.
- Reasons to return to the emergency department: Worsening of suicidal ideation, development of a suicide plan, or any new concerning symptoms.
"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"
**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. Focus on reports from RCMP, psychiatric details] (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)
[Summarize the patient's past psychiatric history, including previous diagnoses, psychiatric treatments (e.g., medications, psychotherapy), hospitalizations, suicide attempts, or other relevant mental health interventions. Include dates, duration of treatment, and outcomes, if available. (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)]
- [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] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave entire section blank)
**PHYSICAL EXAM:**
[General appearance findings, not mentioned anywhere else below] (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)
[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)
Toxidrome: no evidence of clinical toxidrome, pupil
[Neck 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)
CVS: normal S1/S2, no S3/S4 or murmurs (Modify as needed to reflect the transcript. Include this section only if the CVS exam is explicitly mentioned; otherwise, omit it entirely.) (If the exam findings are stated as "normal heart sounds," or "normal cardiac exam," do not change any of the fixed text.)
Resp: chest clear to auscultation, no crackles/wheezes, no crepitus (Modify as needed to reflect the transcript. Include this section only if respiratory exam findings are explicitly mentioned; otherwise, omit it entirely.) (If the exam findings are stated as "normal lungs" or "chest is clear" or "normal respiratory exam," do not change any of the fixed text.)
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics(include only if applicable)]
- Behaviour: [Describe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors (include only if applicable)]
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech (include only if applicable)]
- Mood: [Record the patient's self-described emotional state, using their own words if possible (include only if applicable)]
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood (include only if applicable)]
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations, suicidal ideation / plan / intent, homicidal ideation / plan / intent (include only if applicable)]
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient (include only if applicable)]
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension (include only if applicable)] - Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial (include only if applicable)]
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions (include only if applicable)] (Never come up with your own patient details, assessment, diagnosis, interventions, evaluation, and plan - 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 leave the relevant section blank.)
**INVESTIGATIONS:**
- [List investigations ordered and results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
**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)
