Interval History
Mrs. Evelyn Miller returns today for review. When last assessed by medical oncology in September, she reported fatigue and mild nausea following her first cycle of chemotherapy. She was advised to take anti-nausea medication as needed and to rest when feeling tired.
"Mrs. Miller provided verbal consent to the use of digital transcription and AI scribe technology during this encounter. Purpose, potential benefits, and any associated privacy and security risks of this technology were discussed."
"Today, she reports the following:"
- Persistent but improved fatigue, especially in the afternoons.
- Occasional mild nausea, controlled with medication.
- Reports a good appetite.
- No new symptoms.
- No changes in bowel habits.
Assessment/Plan
Mrs. Miller is tolerating her chemotherapy regimen well, with manageable side effects. Her blood counts have recovered, and her tumour markers remain stable. She will continue with her current chemotherapy protocol. She is scheduled for her next cycle in two weeks. She was advised to continue taking her anti-nausea medication as prescribed. She was encouraged to maintain a healthy diet and stay hydrated. She was given a follow-up appointment in one month.
"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."
Medical Oncology
Interval History
[Patient first name] returns today for review. When last assessed by medical oncology in [month of last visit], she reported [briefly summarize any symptoms or signs reported at last visit and any treatments or interventions recommended at that time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, if available. Write in a single paragraph of full sentences.)
"[Patient first name] provided verbal consent to the use of digital transcription and AI scribe technology during this encounter. Purpose, potential benefits, and any associated privacy and security risks of this technology were discussed." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"Today, she reports the following:"
- [report details of the patient's current symptoms, experiences, new health conditions, changes in medications, or changes in condition since the last assessment, covering various bodily systems and general well-being] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never include interpretation of symptoms, signs, side effects, blood work, diagnostic imaging, or pathology reports in this section. Never include treatment recommendations in this section. Write as a bulleted list.)
Assessment/Plan
[Patient first name] is [provide an overall assessment of the patient's current status, clinical response, tolerance to treatment, and any relevant plan for ongoing care, including consultations, investigations, or follow-up appointments, detailing any specific issues or considerations regarding the patient's condition or treatment plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences with a separate sentence for each assessment item.)
"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."
Medical Oncology
(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.)