General ED Note_ES

[Age] (If adult patient, write the age in years with yo after the number. If a paediatric patient, write the age in years and/or months, with yo for years and mon for months. Example: 3yo 4mon.) [Gender] (Indicate as male or female.) [List any allergies to medications, latex, food or other substances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If noted as no allergies, write "No allergies known". If not mentioned, omit completely.) [Pregnancy and obstetrics details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. Use GxPxMxEx format with gestational age and booking details where available.) [List any known chronic conditions] (Only include if explicitly mentioned. If not mentioned, omit completely. If explicitly noted, write "No known chronic conditions".) [Detail past medical history not included under chronic conditions, including resolved conditions, previous surgeries] (Only include if explicitly mentioned; otherwise omit completely.) [List chronic medication taken for known chronic conditions, with dosages and frequency where possible] (Only include if explicitly mentioned; otherwise omit completely.) [Detail social history including smoking, alcohol, drug use, work/study, living situation, living conditions, social services, activities of daily living] (Only include if explicitly mentioned; otherwise omit completely.) [Detail any relevant family history of medical conditions, including information about age of onset, severity and which family members are involved] (Only include if explicitly mentioned; otherwise omit completely.) (Only include the following if paediatric patient <13yo.) [RVD status] (Only include if explicitly mentioned; otherwise omit completely.) [Immunisation status] (Only include if explicitly mentioned; otherwise omit completely.) [Birth history details] (Only include if explicitly mentioned; otherwise omit completely.) [Growth status and details] (Only include if explicitly mentioned; otherwise omit completely.) Now c/o: [Brief description of reason for emergency visit, including duration of symptoms if mentioned] (Only include if explicitly mentioned; otherwise omit completely.) - DOI [Date and time of injury] (Only include if explicitly mentioned; otherwise omit completely.) - MOI [Mechanism of injury] (Only include if explicitly mentioned; otherwise omit completely.) [Detail history of presenting illness including onset, duration, severity, associated symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail any negative symptoms to support diagnosis] (Only include if explicitly mentioned; otherwise omit completely.) [Detail current medication taken for presenting illness, including dosages, frequency, and timing if available] (Only include if explicitly mentioned; otherwise omit completely.) [Detail constitutional symptoms such as weight change, fever, chills, night sweats, fatigue, malaise, loss of appetite] (Only include if explicitly mentioned; otherwise omit completely.) [Detail eye-related symptoms such as pain, swelling, redness, discharge, vision changes] (Only include if explicitly mentioned; otherwise omit completely.) [Detail ENT symptoms such as hearing changes, ear pain, nasal congestion, sore throat, swallowing difficulty] (Only include if explicitly mentioned; otherwise omit completely.) [Detail cardiovascular symptoms such as dizziness, chest pain, shortness of breath, palpitations, oedema] (Only include if explicitly mentioned; otherwise omit completely.) [Detail respiratory symptoms such as cough, sputum, wheezing, dyspnoea] (Only include if explicitly mentioned; otherwise omit completely.) [Detail gastrointestinal symptoms such as nausea, vomiting, diarrhoea, constipation, abdominal pain, reflux] (Only include if explicitly mentioned; otherwise omit completely.) [Detail genitourinary symptoms such as dysuria, frequency, haematuria, flank pain, incontinence] (Only include if explicitly mentioned; otherwise omit completely.) [Detail gynaecological/obstetric symptoms such as vaginal bleeding, dysmenorrhoea, DUB, dyspareunia] (Only include if explicitly mentioned; otherwise omit completely.) [Detail musculoskeletal symptoms such as arthralgias, myalgias, stiffness, back pain, injury history] (Only include if explicitly mentioned; otherwise omit completely.) [Detail dermatological symptoms such as rash, lesions, pruritus, skin or hair changes] (Only include if explicitly mentioned; otherwise omit completely.) [Detail neurological symptoms such as weakness, numbness, headache, syncope, coordination changes, falls] (Only include if explicitly mentioned; otherwise omit completely.) [Detail psychiatric symptoms such as mood, anxiety, depression, insomnia, delusions, hallucinations, suicidal or homicidal ideation. If explicitly mentioned in transcript, include quotations of what patient said.] (Only include if explicitly mentioned; otherwise omit completely.) [Detail endocrine symptoms such as polyuria, polydipsia, temperature intolerance] (Only include if explicitly mentioned; otherwise omit completely.) [Detail haematologic/lymphatic/oncology symptoms such as bruising, bleeding, transfusion history, lymphadenopathy] (Only include if explicitly mentioned; otherwise omit completely.) [Detail allergic/immunologic symptoms such as allergic reactions or autoimmune disorders] (Only include if explicitly mentioned; otherwise omit completely.) Vitals: BP [Blood pressure mmHg], HR [Heart rate bpm], RR [Respiratory rate bpm], Sats [Oxygen saturation %, indicate RA or FiO2%], T [Temperature °C] (Always include if explicitly mentioned; if paediatric patient, include weight as recorded.) [Hb] (Only include if explicitly mentioned; otherwise omit completely.) [Hgt] (Only include if explicitly mentioned; otherwise omit completely.) [Udip] (Only include if explicitly mentioned; otherwise omit completely.) [Urine prognostic] (Only include if explicitly mentioned; otherwise omit completely.) Examination: GEN: [General examination findings e.g. jaundice, anaemia, cyanosis, oedema, dehydration. If not mentioned, include negative general findings.] CNS: [Neurological findings] (Only include if explicitly mentioned; otherwise state no abnormal findings.) ENT: [Ear, nose, throat findings] (Only include if explicitly mentioned; if paediatric and not mentioned, state no abnormal findings.) RESP: [Respiratory findings] (Only include if explicitly mentioned; otherwise state no abnormal findings.) CVS: [Cardiovascular findings] (Only include if explicitly mentioned; otherwise state no abnormal findings.) ABD: [Abdominal findings] (Only include if explicitly mentioned; otherwise state no abnormal findings.) GYN: [Gynaecological findings] (Only include if explicitly mentioned; otherwise omit completely.) OBS: [Obstetric findings] (Only include if explicitly mentioned; otherwise omit completely.) GU: [Genitourinary findings] (Only include if explicitly mentioned; otherwise omit completely.) MSK: [Musculoskeletal findings] (Only include if explicitly mentioned; otherwise omit completely.) DERM: [Skin findings] (Only include if explicitly mentioned; otherwise omit completely.) PSYCH: [Psychiatric findings] (Only include if explicitly mentioned; otherwise omit completely.) OPTHAL: [Ophthalmological findings] (Only include if explicitly mentioned; otherwise omit completely.) [ICD-10 diagnosis codes] (Include ICD-10 code(s) for all explicitly mentioned diagnoses. If primary injury/trauma code is used, also include ICD-10 code for mechanism of injury.) Assessment: [Main diagnosis] (Only include if explicitly mentioned; otherwise omit completely.) [Haemodynamic stability] (Only include if explicitly mentioned; otherwise omit completely.) [Respiratory distress or failure, including type] (Only include if explicitly mentioned; otherwise omit completely.) [Additional diagnoses] (Only include if explicitly mentioned; otherwise omit completely.) DOI [Date and time of injury, if explicitly mentioned] MOI [Mechanism of injury, if explicitly mentioned] Differential: [List differential diagnoses in descending order of likelihood. Only include if explicitly mentioned in transcript, contextual notes or clinical note.] Plan: [IV access and fluid details] (Only include if explicitly mentioned; otherwise omit completely.) [Medication details] (Only include if explicitly mentioned; otherwise omit completely.) [Investigations details] (Only include if explicitly mentioned; otherwise omit completely.) [Point of care investigations] (Only include if explicitly mentioned; otherwise omit completely.) [Blood tests details] (Only include if explicitly mentioned; otherwise omit completely.) [Procedures details] (Only include if explicitly mentioned; otherwise omit completely.) [Counselling details] (Only include if explicitly mentioned; otherwise omit completely.) [Discussion and shared decision making with patient/family] (Only include if explicitly mentioned; otherwise omit completely.) [Specialist discussion details] (Only include if explicitly mentioned; otherwise omit completely.) [Disposition details] (Only include if explicitly mentioned; otherwise omit completely.) [Outpatient specialist referral details] (Only include if explicitly mentioned; otherwise omit completely.) [Outpatient GP referral details] (Only include if explicitly mentioned; otherwise omit completely.) [Follow up plan details] (Only include if explicitly mentioned; otherwise omit completely.) [Review plan details] (Only include if explicitly mentioned; otherwise omit completely.) (Use the following abbreviations if applicable: DC = discharge; TTO = outpatient prescription; MOI = mechanism of injury; DOI = date/time of injury; DW = discussed with; NAD = no abnormalities detected; NVI = neurovascular intact; ROM = range of movement; RA = room air; NPO2 = nasal prong oxygen; FMO2 = face mask oxygen; FiO2 = supplemental oxygen; USS = ultrasound; CXR = chest x-ray; PXR = pelvis x-ray; XR = x-ray; ECG = electrocardiogram; ml/hr = millilitres per hour; mcg/kg/min = micrograms per kilogram per minute. Do not abbreviate medical conditions or illnesses.) (Use date format dd/mm/yyyy and time format hh:mm.) (When the word "query" appears in transcript, replace with "?" immediately attached to the word that follows.) (For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)