Chief Complaint:
[presenting issue or complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as short phrase.)
[details of reason for visit, current issues including relevant signs and symptoms, and associated signs and symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.)
Review of Systems:
[constitutional symptoms including weight change, fever, chills, night sweats, fatigue, malaise] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[eye-related symptoms including pain, swelling, redness, discharge, vision changes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[ENT-related symptoms including hearing changes, ear pain, congestion, sinus pain, sore throat, rhinorrhea, swallowing difficulty] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[cardiovascular symptoms including chest pain, SOB, PND, DOE, orthopnea, palpitations, edema, claudication] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[respiratory symptoms including cough, sputum, wheeze, smoke exposure, dyspnea] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[gastrointestinal symptoms including nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, anorexia, dysphagia, hematochezia, melena, jaundice] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[genitourinary symptoms including dysuria, frequency, hematuria, incontinence, urgency, flank pain, menstrual/sexual history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[musculoskeletal symptoms including arthralgia, myalgia, stiffness, swelling, back pain, neck pain, injury history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[skin symptoms including lesions, rash, pruritus, hair/nail changes, nipple discharge] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[neurological symptoms including weakness, numbness, paresthesias, dizziness, headache, LOC, syncope, falls, coordination changes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[psychiatric symptoms including anxiety, depression, insomnia, hallucinations, delusions, suicidal/homicidal ideation, eating concerns, memory changes, abuse/violence history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[endocrine symptoms including polyuria, polydipsia, temperature intolerance] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[hematologic/lymphatic symptoms including bruising, bleeding, transfusion history, lymphadenopathy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[allergic/immunologic symptoms including allergic reactions, autoimmune disorders] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Past Medical History:
[known chronic medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[previous surgeries or hospitalisations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[previous investigations such as ECG, ultrasound, pathology if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Medications:
[current medications and dosages] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Allergies:
[any known allergies, especially to medications, with reaction if stated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Social History:
[smoking history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[alcohol use] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[illicit drug use] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[occupation or schooling] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Family History:
[relevant family medical history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Physical Examination:
[vital signs including BP, HR, RR, Temp, O2 sats if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[general state of health and notable findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[CNS findings including mental status, cranial nerves, coordination, reflexes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[CVS findings including HR, rhythm, murmurs] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[respiratory exam including breath sounds, wheeze, crackles] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[abdominal exam including tenderness, bowel sounds, organomegaly] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[musculoskeletal exam including ROM, strength, deformities] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Differential Diagnosis:
[differential diagnoses considered] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Investigations Ordered/Planned:
[tests ordered such as bloods, ECG, imaging] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Investigation Results:
[pathology results including blood/urine tests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[imaging results including X-ray, CT, MRI, US] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[other investigations including ECG, echo, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Impression:
[working or confirmed diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.)
Plan:
[initial treatment provided in ED or clinic] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[further investigations pending or planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[disposition e.g. admit, discharge, follow-up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[referrals to specialties or allied health] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
(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 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.)
