Extended Care Paramedic (Copy)

PRESENTING COMPLAINT - [Detail presenting complaints] (Use as many bullet points as needed to capture the reason for the visit and any associated stressors in detail. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING COMPLAINT - [Detail the history of the presenting complaint(s) including onset, duration, course, quality and severity of the symptoms or problems] (Write in detailed story form to capture when the symptoms or problem started, the development and course of symptoms. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SYSTEMS REVIEW General: [General appearance and status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CVS: [Cardiovascular examination findings] (Do not start a new line for each finding. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Resp: [Respiratory examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Abdo: [Abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neuro: [Neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MSK: [Musculoskeletal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) GU: [Gastrourinary examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) TREATMENT [Treatment provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PLAN [Detailed information including GP details, urgent care center, community nurse, referral pathway] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EXCLUSIONS AND RED FLAGS [Exclusions and red flags] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RISKS [Specific risks associated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) WORSENING CARE ADVICE and ACTION PLAN [Advice for ongoing management, advice if clinically deteriorating and steps to take, documentation left with patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES [Known drug allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICAL HISTORY - [Detail personal and family medical history] (Use as many bullet points as needed to capture the patient's medical history and the patient's family medical history. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS [Current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY [Mention relevant social history including shopping, cooking, cleaning, mobility, care received, living arrangements, support network, key safe details etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Ensure all information discussed in the transcript is included under the relevant heading or sub-heading above, otherwise include it as a bullet-pointed additional note at the end of the note.) (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 section blank.) (Ensure all information is super detailed and do not use quotes.)