Clinician Specialty: General Practitioner
**Health Assessment for a Person with Intellectual Disability**
"Patient consents to participating in health assessment - verbal consent"
Patient: Sarah Jenkins
DOB: 15/05/1990
Carer present: yes
Date: 1 November 2024
GP: Dr. Eleanor Vance
**1. Time-Tiered Item Selection (Medicare)**
"701/703/705/707"
"Claimable once every 12 months per eligible patient."
**2. Checklist (Consult Prompts)**
**A. History & Function**
Physical, psychological, and social function reviewed: Patient presents with mild intellectual disability. Physical function stable, participates in light recreational activities. Psychological function stable with occasional anxiety related to changes in routine. Social function adequate with family and support worker.
ADL supports adequate: yes, uses support worker for complex tasks like financial management and medical appointment scheduling.
Mental health / comorbidities:
* Mild Anxiety Disorder
* Hypothyroidism (controlled with medication)
Seizure history: No history of epilepsy.
**B. Examination & Screening**
Dental: normal, regular dental check-ups.
Hearing (audiometry <5y?): yes
Vision (eye check <5y?): yes
Height / Weight / BMI: Height: 160 cm, Weight: 70 kg, BMI: 27.3 (overweight)
Nutrition: concern, patient tends to prefer processed foods, working on healthier choices with support worker.
Bowel/bladder: normal
Dysphagia / GERD (esp CP): no
Abuse concerns considered: yes, discussed with patient and carer, no concerns identified.
**C. Medications**
Prescribed meds reviewed: yes
Non-prescription meds reviewed: yes
Side effects / interactions discussed: Discussed potential side effects of levothyroxine, patient reports no issues. No significant interactions identified with current medications.
Carer education provided: yes
Medication review needed: no
Medication list:
* Levothyroxine 75mcg daily
* Sertraline 50mg daily
**D. Preventive Health**
Immunisations: up to date
Exercise: inadequate, patient struggles with motivation for regular exercise.
Screening as per general population:
Breast exam / Mammogram: yes
Cervical screening: yes
Testicular exam: NA
Lipids: yes
Osteoporosis risk assessed: yes
Thyroid function: 1 November 2024 / next due 1 November 2025
**3. Management Plan**
Key issues identified:
* Management of overweight status and nutrition.
* Encouraging regular exercise.
* Ongoing monitoring of anxiety.
Preventive care initiated: Referral to dietician for nutritional guidance. Discussed strategies to incorporate more physical activity into daily routine.
Referrals:
* Dietician
* Local walking group
Lifestyle advice: Encouraged daily walks and mindful eating. Suggested joining a local social group to increase physical activity and social interaction.
**4. Reporting & Documentation**
Written summary offered to patient: yes
Copy to carer (with consent): yes
"Report saved in notes"
**Health Assessment for a Person with Intellectual Disability**
"Patient consents to participating in health assessment - verbal consent"
Patient: [patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
DOB: [date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Carer present: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Date: [date] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
GP: [GP name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
**1. Time-Tiered Item Selection (Medicare)**
"701/703/705/707"
"Claimable once every 12 months per eligible patient."
**2. Checklist (Consult Prompts)**
**A. History & Function**
Physical, psychological, and social function reviewed: [function review] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
ADL supports adequate: [yes/no and details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If no, consider review.)
Mental health / comorbidities: [medical and mental health problems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List all medical and mental health problems in bullet form.)
Seizure history: [seizure control, medications, neurology review needed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If no epilepsy, do not mention this item.)
**B. Examination & Screening**
Dental: [normal/abnormal and action] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Hearing (audiometry <5y?): [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Vision (eye check <5y?): [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Height / Weight / BMI: [values] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Nutrition: [adequate/concern] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Bowel/bladder: [normal/abnormal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Dysphagia / GERD (esp CP): [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Abuse concerns considered: [yes/no and action] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
**C. Medications**
Prescribed meds reviewed: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Non-prescription meds reviewed: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Side effects / interactions discussed: [details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Carer education provided: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Medication review needed: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Medication list: [medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List all medications in bullet form.)
**D. Preventive Health**
Immunisations: [up to date / due with list] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Exercise: [adequate/inadequate] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Screening as per general population:
Breast exam / Mammogram: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Cervical screening: [yes/no/NA] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Testicular exam: [yes/no/NA] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Lipids: [yes/no/NA] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Osteoporosis risk assessed: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Thyroid function: [date / next due] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank. Check at least every 2 years; yearly if Down syndrome.)
**3. Management Plan**
Key issues identified: [key issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate issues that were not discussed. List in bullet form.)
Preventive care initiated: [preventive care details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
Referrals: [referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate referrals that were not discussed. E.g. dentist, audiology, optometry, neurology, allied health, mental health.)
Lifestyle advice: [lifestyle advice] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. E.g. exercise, nutrition, sleep, carer support.)
**4. Reporting & Documentation**
Written summary offered to patient: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Copy to carer (with consent): [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Only include if a carer is present.)
"Report saved in notes"
