Medicolegal template 2

Location of Assessment: [Location of assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Subjective - Presenting complaint and duration: [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Associated symptoms: [Include relevant positives and negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Past medical/surgical history: [Include if relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Current medications and allergies: [List if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Social or travel context: [Social or travel context] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective - Vital signs: [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - General condition: [General condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Focused exam findings: [Focused exam findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Red flags excluded: [Red flags excluded] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Prior investigations discussed: [Prior investigations discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment - Working diagnosis: [Working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Differential diagnoses: [Differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - (Include reasoning if uncertain: "No current red flags to suggest need for immediate escalation") Plan - Treatment given: [Treatment given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - (State consent if given: "Verbal consent obtained after discussion of benefits and side effects") - Follow-up plan: [Follow-up plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Safety-netting: [Safety-netting instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Referral: [Referral details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Capacity: [Capacity details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Companion: [Companion details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Travel advice: [Travel advice] (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 come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)