**Consent & Pre-Procedure Details**
Patient consent was documented for the use of AI in documentation. Screening for Body Dysmorphic Disorder (BDD) was performed, and the patient did not exhibit any signs of BDD. Written and verbal consent for the procedure was confirmed.
Discussion and agreement on the cost, treatment plan, benefits, risks, and alternatives were detailed, ensuring the patient fully understood the procedure.
The procedures provided were summarized, all questions were answered, and all issues were addressed.
Cost of procedure: £500
Key points discussed:
The treatment goals, expected results, longevity, and downtime were discussed, ensuring the patient had realistic expectations.
Changes in medications or health concerns:
No changes in medications or health concerns were mentioned.
Content of discussion:
The discussion covered the progress of the patient, management plans, effects of treatments, aftercare, and any new technologies discussed.
**Products Used**
– Product name: Radiesse
– Volume (mL): 1.5 mL
– Batch number: ABC123
– REF: REF456
– Expiry date: 01/01/2026
– Notes (if multiple products used): Used for cheek augmentation.
– Product name: Dysport
– Volume (mL): 50 units
– Batch number: DEF456
– REF: REF789
– Expiry date: 01/06/2025
– Notes (if multiple products used): Used for forehead lines.
**PRP**
– RPM: 2000
– Duration (mins): 10
**Procedure Details & Summary**
– Aseptic technique: Standard aseptic technique was used, including cleaning the skin with chlorhexidine.
– Safety checks: All safety checks were performed, including checking the product expiry dates and patient allergies.
Procedure description:
Radiesse with PRP was administered to the cheeks for volume enhancement and skin rejuvenation. The procedure was performed with careful attention to detail, ensuring even distribution and patient comfort.
Dysport was administered to the forehead to reduce the appearance of wrinkles. The injection sites were carefully marked, and the injections were performed with precision.
– Tolerance: The patient tolerated the procedure well, with minimal discomfort and no immediate complications.
– Aftercare: The patient was instructed to avoid strenuous activity for 24 hours, apply ice packs as needed, and contact the clinic if any unusual symptoms occurred.
– Follow-up: A follow-up appointment was scheduled for 2 weeks to assess the results and address any concerns.
**History of Presenting Complaint (HPC)**
The patient presented for cheek augmentation and forehead wrinkle reduction, expressing a desire for a more youthful appearance. She reported feeling self-conscious about the loss of volume in her cheeks and the appearance of forehead lines.
**Past Medical History**
No previous cosmetic treatments. No ongoing medical conditions or relevant disorders.
**Medications and Allergies**
Current medications & supplements: None.
Allergies: No known allergies.
**Family History**
No significant family history.
**Session Content**
The session content included patient satisfaction, discussions about physiological effects, side effects, management plans, examination findings, and agreed-upon procedures.
**Plan for Next Session**
Next appointment: 1 November 2024
The plan for the next session includes a review of the results, assessment of specific areas, and continuation of current management plans.
**Consent & Pre-Procedure Details**
[Document patient consent to AI use in documentation, screening for Body Dysmorphic Disorder (BDD), and confirmation of written and verbal consent for the procedure] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Detail discussion and agreement on cost, treatment plan, benefits, risks, and alternatives] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Summarize procedures provided, confirmation of all questions answered, and issues addressed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Cost of procedure: [Specify the cost of the procedure in monetary value] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
Key points discussed:
[Outline treatment goals, expected results, longevity, and downtime discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Changes in medications or health concerns:
[Document any changes in medications or health concerns mentioned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Content of discussion:
[Describe the content of the discussion, including progress, management plans, effects of treatments, aftercare, and any new technologies discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
**Products Used**
(Repeat the following product entry format for each product used during the session.)
– Product name: [Record the name of the product used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Volume (mL): [Specify the volume in mL of the product used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Batch number: [Document the batch number of the product] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– REF: [Document the REF of the product] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Expiry date: [Record the expiry date of the product] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Notes (if multiple products used): [Add any specific notes if multiple products were used or mixed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
**PRP**
– RPM: [Document the revolutions per minute for PRP] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Duration (mins): [Document the duration in minutes for PRP] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
**Procedure Details & Summary**
– Aseptic technique: [Describe the aseptic technique used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Safety checks: [Detail the safety checks performed prior to the procedure] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
Procedure description:
[Describe the procedure involving Radiesse with PRP] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Describe the procedure involving Dysport administration] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Describe the procedure involving Xeomin administration] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
– Tolerance: [Document patient tolerance to the procedure and any immediate complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Aftercare: [Detail the aftercare instructions provided, including red-flag symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
– Follow-up: [Outline the planned follow-up details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
**History of Presenting Complaint (HPC)**
[Describe the patient's presenting complaint, including reasons for follow-up, reported changes, concerns, and associated symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
**Past Medical History**
[Document the patient's past medical history, including previous cosmetic treatments, ongoing medical conditions, and any relevant disorders] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
**Medications and Allergies**
Current medications & supplements: [List current medications and supplements the patient is taking] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
Allergies: [Document any known allergies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
**Family History**
[Document details regarding the patient's family history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
**Session Content**
[Summarize the content of the session, including patient satisfaction, discussions about physiological effects, side effects, management plans, examination findings, and agreed-upon procedures] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
**Plan for Next Session**
Next appointment: [Specify the date of the next appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write on the same line.)
[Detail the plan for the next session, including review of results, assessment of specific areas, and continuation of current management plans] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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.)
