Scribe BC - ED admission note

Scribe BC - ED admission note Chief Complaint - Presenting Issue: [Brief description of the presenting issue or complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of the reason for visit, current issues including relevant signs and symptoms, as well as associated signs and symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical History - [Any known chronic medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of previous surgeries or hospitalizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Medications: [Current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Allergies: [Any known allergies, particularly to medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History - [Current or past smoking history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - [Alcohol consumption habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - [Any illicit drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - [Current or previous occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Family History - [Relevant family medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Physical Examination - Vital Signs: [Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - General examination: [General state of health and any notable findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - CVS: [Heart rate, rhythm, and any murmurs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Resp: [Breath sounds, any wheezes or crackles] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Abdo: [Palpation, bowel sounds, any tenderness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - MSK: [Range of motion, strength, any deformities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Neuro: [Mental status, cranial nerves, coordination, reflexes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Investigations - Pathology: [Blood tests, urine tests, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Imaging: [X-rays, CT scans, MRIs, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Other Investigations: [ECG, ultrasound, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Assessment - [Presumed diagnosis based on consult summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Plan/Treatment - Immediate Management: [Details of treatment administered in the ED] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Investigations: [Plans for additional diagnostic tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Referrals: [Referrals to specialists or other departments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Discharge & Follow-up Instructions: [Instructions for patient dicharge and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Emergency "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, or 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.)