Scribe BC - 811 Consult

ID: - [Patient name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) is a [Patient age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Patient gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) CC: - [Chief complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) HPI: - [Describe history of presenting illness, including onset, duration, and characteristics of symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Include review of systems under history of presenting illness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.): - Constitutional symptoms: [Symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise] - Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes] - Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty] - Cardiovascular: [Symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations] - Respiratory: [Symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea] - Gastrointestinal: [Symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice] - Genitourinary: [Symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy] - Musculoskeletal: [Symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history] - Integumentary (Skin): [Symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge] - Neurological: [Symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls] - Psychiatric: [Symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns] - Endocrine: [Symptoms like Polyuria, Polydipsia, Temperature intolerance] - Hematologic/Lymphatic: [Symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy] - Allergic/Immunologic: [Symptoms like Allergic reactions, Auto-immune disorders] PMHX: - [Describe past medical history, including previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) MEDS: - [Mention current medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) ALLERGIES: - [Mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) FAMILY HISTORY: - [Family history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) SOCIAL HX: - [Describe social history, including smoking, alcohol use, and occupation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Do not include physical exam or investigations sections] IMPRESSION / PLAN: - [Impression, including working diagnosis and differential diagnoses mentioned: Medications with doses, Procedures etc (only include if explicitly mentioned)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Plan, including treatment and follow-up] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Referrals: Specialty consultations (only include if explicityly mentioned)] - [Discharge Criteria: Conditions for discharge or admission (only include if explicityly mentioned)] - [Follow-up: Instructions for follow-up care and reasons to return to the emergency department (only include if explicity mentioned)] "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, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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 omit the placeholder completely if not mentioned.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information) (always bold section headings, this is very important)