Reforme Consultation

[Patient name and surname] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.), [Patient age] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.), [Patient sex] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.), [Patient date of birth] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely. Write in format DD/MM/YYYY.), [Patient postcode] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.), [Patient occupation] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.), consent for Reforme to contact GP. Source Of Inquiry: [Source of inquiry] (Only include if explicitly mentioned in the transcript, context or clinical note, otherwise omit section entirely.) "Refer to Medical Questionnaire and Treatment Questionnaire in Patient Folder for medical history." Chaperone: [Chaperone status during examination and treatment] (Only include if explicitly mentioned in the transcript, context or clinical note; if not mentioned write "Chaperone present or available at patient's request.") Patient Requesting Medical Advice About: [Description of the medical advice the patient is requesting] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Allergy History: [Patient allergy status] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) [Reported reaction or lack of reaction to previous local anaesthesia] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Medical History: [Relevant past medical history] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) [Nicotine exposure status] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely.) [Indicate if nicotine risk and abstinence advice was given by writing "Advice regarding risks of Nicotine exposure and need for abstinence for 4 weeks before and after treatment given”] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely.) [Recreational drug use status] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely.) Past Treatment History: [Relevant past treatment history] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Ongoing Medications: [Ongoing medications explicitly mentioned] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No ongoing medications." Write on a single line.) "No history of being unable to lie flat for 2 hours." "No history of operations or diagnosed hernias in the treatment area." "No implant in treatment area or vicinity." "No history of thrombophlebitis, clots, DVT, or PE." "No history of liver disorders or Cytochrome 450 deficiency." DRUG INTERACTIONS WITH MEDICATIONS TO BE USED FOR SURGERY: [Documented drug interaction concerns if the patient is on any medication] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Absolute And Relative Contraindications: Allergies: [History of allergies] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit. Write in full sentences.) "No allergies reported to medications or agents commonly used in treatment." (Always include in notes unless there is mention of allergies to above in transcript, context or clinical notes) "No adverse reactions to past local anaesthesia treatments reported." (Always include in notes unless there is mention of allergies to above in transcript, context or clinical notes) Keloidal Scarring: [History of keloidal scarring] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No history of keloidal scarring." Write in a paragraph.) Pregnancy / Breastfeeding: [Pregnancy or breastfeeding status] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No ongoing pregnancy or breastfeeding reported." Write in a paragraph.) Body Dysmorphic Disorder: [BDD concerns or assessment] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "Body dysmorphic disorder not suspected." Write in a paragraph.) Blood-Thinning Agents: [Use of blood thinners or supplements increasing bleeding risk] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No use of blood thinners or supplements affecting bleeding risk reported." Write in a paragraph.) Infections: [Reported ongoing infections] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No ongoing infections reported." Write in a paragraph.) Active Skin Conditions: [Active acne, lesions, inflammatory conditions] (Only include if explicitly mentioned in the transcript, context or clinical note, else write "No active acne or inflammatory lesions reported." Write in a paragraph.) [Cold sores, eczema or psoriasis in treatment area] (Only include if explicitly mentioned, else write "No history of cold sores, eczema or psoriasis in the treatment area reported." Write in a paragraph.) Psychological Questionnaire Score: "Psychological questionnaire score is used to assess psychological impact of the presenting problem and the reason for seeking treatment." Patient Scores: [Patient's questionnaire score] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph.) [Clarification related to score zero] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit.) Patient Expectation From Treatment: [Patient expectations for treatment outcome] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit section entirely. Write in a paragraph.) [Assessment of expectation realism or body dysmorphia concerns] (Only include if explicitly mentioned in the transcript, context or clinical note, else omit.) Does Patient Need Caprini Score Assessment: [Whether patient requires Caprini score assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit. Write in a paragraph.) Patient Evaluation: HEIGHT (cms): [Height] (Only include if explicitly mentioned in transcript, context or clinical note, else omit.) WEIGHT (kg): [Weight] (Only include if explicitly mentioned in transcript, context or clinical note, else omit.) BMI: [BMI] (Only include if explicitly mentioned in transcript, context or clinical note, else omit.) PR: [Pulse rate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit.) BP: [Blood pressure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit.) SAT (ON AIR): [Oxygen saturation] (Only include if explicitly mentioned, else omit.) On Examination: [Physical examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit. Write in a paragraph.) "SEE TREATMENT SUPPLEMENT" Medical Impression / Diagnosis: [Clinician’s medical impression or stated diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit completely. Write in a paragraph. Do not infer or assume a diagnosis.) ICD Codes Applicable: [Applicable ICD codes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit. Write as bullet points.) Treatment Options Discussed: Option 1: [Option of not having treatment] (Always include; write on one line.) Option 2: [Discussed treatment option] (Only include if explicitly mentioned, else omit. Write in a paragraph.) Informed Consent: [Statement confirming treatment options including no treatment were explained] (Always include; write on a single line.) [Explanation of treatment process, risks, and care requirements] (Always include; write on a single line.) [Use of case studies] (Always include; write on a single line.) [Clarification regarding photos and outcome expectations] (Always include; write on a single line.) [Statement confirming patient's questions were answered] (Always include; write on a single line.) [Confirmation forms were provided] (Always include; write on a single line.) [Follow-up plan after reviewing information] (Always include; write on a single line.) [Warning about limitations of medical and surgical treatments] (Always include; write on a single line.) [Information about dissatisfaction rates in cosmetic surgery] (Always include; write on a single line.) Treatment Plan Quote: [Details of the treatment plan quote] (Only include if explicitly mentioned in transcript, context or clinical note, else omit. Write in a paragraph.)