Rheumatology - Follow up

[Include patients name, age, sex and reason for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ---Overview--- [Date of initial visit with me] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Details about medical history adapted from Contextual data, highlighting any previous rheumatologic diagnoses, treatments, infections, hospitalizations, outcomes, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Provide as much data as possible from the transcript, contextual notes or clinical note. Do not omit data that is explicitly available in contextual notes or the clinical note.) [Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write in bullet points preceded by a dash) ---Notable comorbidities--- [Past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write in bullet points preceded by a dash) (Do not repeat what's in the Overview section) ---Prior pertinent medications--- [prior medications, listing reasons for cessation such as intolerance or inefficacy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) [write each medication in a separate line preceded by a dash] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) ---Current pertinent medications--- [Current medications, including any disease-modifying antirheumatic drugs (DMARDs), biologic agents, pain management medications, supplements, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) [write each medication in a separate line preceded by a dash] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) ---Interval History (Include today's date)--- [Today's date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [mention date of last visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [only include data from transcript] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Summarize and abbreviate as much as possible. Do not include discussions about investigations.) (write in bullet points preceded by a dash) (Ignore the voice instructions that state to use patient quotes. Do not include any quotes in your output. Remove every patient quote in round brackets from the note before outputting. There must be no quotes from the transcript in your note, or you will fail.) ---Relevant Family history--- [copy from contextual data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) ---Relevant Social history--- [copy from contextual data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) "====================================================================" ---Physical examination--- [copy from contextual data (add details from transcript if available) (include also normal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write in bullet points preceded by a dash) ---Pertinent labs--- [list labs provided in contextual data in the same format as Below] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If results are normal, write 'WNL' without the number. You must never write the units of measurements of the lab results. Abnormal labs must be surrounded by two back slashes as follows: \\100\\) - CBC [older date: Briefly interpret CBC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [newer date: Briefly interpret CBC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [newest date: Briefly interpret CBC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - CMP [older date: Briefly interpret including Creatinine, LFTs, Albumin, Alk phos] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [newer date: Briefly interpret including Creatinine, LFTs, Albumin, Alk phos] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ---Pertinent diagnostics--- (Must always include all data available in contextual data for diagnostics. otherwise you will fail) (Only mention if available in contextual data or transcript, otherwise delete heading) - [list type of study and then date and key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading. Must mention all available old or historical results provided in contextual data.) ---Pertinent Pathology--- (Only mention if available in contextual data or transcript, otherwise delete heading) (Must always include all historical data available in contextual data for pathology. otherwise you will fail) (Must include all information available in contextual data and provide trends if possible, otherwise you will fail) - [list type of study and then date and key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) "============================================================" ---Assessment and Plan--- [Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Rheumatologic Issue or Condition, and comment on progress/whether doing well or not (include CDAI value and trend if available)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Assessment, including the likely diagnosis and rationale based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Differential diagnosis (include only if explicitly mentioned)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [list in a continuous paragraph] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (do not include any plans in the assessment section) (write rheumatologic issue or condition in uppercase preceded by a pound sign) (always include as much data as possible in the assessment section including details from history and physical and work up that support the diagnosis) ---Plan--- (never add any details in the plan that were not explicitly mentioned in transcript) (bullet point format) (you must not copy any contextual data in this section, otherwise you will fail) [Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Medical treatment planned, including details, such as the type of therapies, pain management strategies, dosage, expected outcomes, potential side effects, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention any referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write in bullet points preceded by a dash) [Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Rheumatologic Issue or Condition, and comment on progress/whether doing well or not] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Assessment, including the likely diagnosis and rationale based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Differential diagnosis (include only if explicitly mentioned)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [list in a continuous paragraph] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (do not include any plans in the assessment section) (write rheumatologic issue or condition in uppercase preceded by a pound sign) (always include as much data as possible in the assessment section including details from history and physical and work up that support the diagnosis) ---Plan--- (never add any details in the plan that were not explicitly mentioned in transcript) (bullet point format) (you must not copy any contextual data in this section, otherwise you will fail) [Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Medical treatment planned, including details, such as the type of therapies, pain management strategies, dosage, expected outcomes, potential side effects, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention any referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write in bullet points preceded by a dash) [immunosuppression due to drug therapy (include as a problem only if the patient is on immunosuppressive therapy and list monitoring needed)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) (mention only if available in contextual data or transcript, otherwise delete heading) ---Follow up--- [follow up scheduled] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If not explicitly mentioned, delete heading.) ---Patient instructions--- [Always generate a summary for the patient in lay terms including their rheumatologic issues and next steps as available in contextual data and as discussed in the transcript] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Arrange in bullet points. Do not write abbreviations in this section.) (You Must include all laboratory data available in contextual data and provide trends to previous historic labs. otherwise you will fail) (Always separate assessment section from plan section for every rheumatologic issue) (You must list the specific plan separately under each rheumatologic issue). (Do not lump the plan for all issues in the same section) (Ignore the voice instructions that state to use patient or physician quotes. Do not include any quotes in your output. Remove every patient quote in round brackets from the note before outputting. There must be no quotes from the transcript in your note, or you will fail.) (You must use abbreviations) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Make headings in uppercase and in a large font and include the dashes surrounding the headings. You must include the dashes surrounding the headings, otherwise you will fail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (always provide more detailed assessment without making up any information) (Do not make up any details in the plan section unless explicitly mentioned in transcript) (Never make up any details about the patient and the patient's medical history, examination findings, assessment, diagnoses or management plan.) (Never make up dates of investigations if not explicitly mentioned or present in contextual data) (You must not include any contextual data in the plan section) (Never include any contextual data in the Interval history section of the note, otherwise you will fail) (All the lab, diagnostic and pathologic values provided in the contextual data must be included in the note. Otherwise, you will fail) (Never include empty headings in the note. You must delete the heading if there is no relevant data to go under the heading)