Scribe BC- GI Med Onc Consult

Reason for Consultation "Dear Dr. [consulting physician name]," [Acknowledge referral of the patient, including age, gender, and relevant medical history leading to the current presentation. Include diagnosis, date of diagnosis, staging (TNM), and pertinent pathology details and molecular markers. Also include who the patient is accompanied by if anyone.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) **Consent** "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks" History of Present Illness [Describe the patient's past medical history relevant to the current presentation, including diagnoses, dates, and previous treatments. Elaborate on the presenting symptoms, their duration, and any associated features. Detail the chronological sequence of events, including consultations, investigations, and hospital admissions, along with their findings and implications. Include details about current symptoms, their severity, aggravating/alleviating factors, and impact on daily activities. Document any recent changes in symptoms or general well-being. Mention current medication adherence and any related observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Pathology [Detail the pathology results, including the date of the report, the type of specimen, and the final diagnosis. Provide a summary of the key findings and their clinical significance.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Lab Results [Provide a comprehensive list of relevant lab results, including test names, dates, and values. Highlight any abnormal findings and their clinical interpretation.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Diagnostics Results [Summarize findings from diagnostic imaging and procedures, including the type of imaging/procedure, date, and detailed report. Focus on descriptions of organs, identified lesions, measurements, and any changes from previous studies. Include impression or conclusion of the diagnostic reports.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Medications Home Medications [Document current home medications, including details on whether a best possible medication history was obtained and any discrepancies or adherence issues.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Allergies [List any known allergies, including medication, food, or environmental, and describe the nature of the reactions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Problem List/Past Medical History [Provide a structured problem list or past medical history, detailing each condition with relevant historical context, key events, and previous management. Include details such as diagnosis dates, relevant prior admissions or treatments, and any related complications or ongoing issues.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a list with bullet points for sub-items.) Social History [Document details about the patient's social history, including lifestyle habits (e.g., smoking, alcohol, drug use), living situation, occupation, and financial or social supports. Include duration and frequency of habits, and impact on health.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Family History [Describe relevant family medical history, including significant illnesses, genetic conditions, and age of diagnosis in family members. Focus on conditions pertinent to the patient's current presentation or risk factors.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Performance Status [Assess and document the patient's performance status using a recognized scale (e.g., ECOG/Zubrod), providing details on their functional abilities, activity levels, and independence in daily tasks.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Physical Exam [Provide a systematic report of the physical examination findings, categorized by body system. Include general appearance, vital signs, and specific findings for each system examined, noting any abnormalities or significant observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Assessment/Plan [Provide a comprehensive assessment of the patient's condition, integrating historical, physical, and investigative findings to formulate a diagnosis or clinical impression. Detail the rationale for the diagnosis and discuss the prognosis. Outline the management plan, including further investigations, treatments, referrals, and patient education. Document discussions with the patient regarding their condition, treatment options, potential risks/benefits, and shared decision-making. Include follow-up plans, monitoring, and any specific instructions given to the patient. Detail communications with other healthcare providers involved in the patient's care.] [Patient and family education on the current status of cancer, overview of the treatment plan, potential side effects, and symptom management] [Discussion of patient preferences and goals of care, including advance care planning and quality of life considerations] [Any specific patient or family concerns addressed regarding the cancer diagnosis, treatment options, or prognosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) Medical Oncology "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (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.)