GP Comprehensive Consultation Note

**1. Consultation & Procedural Integrity** **Encounter:** [Face to face "F2F" OR Telehealth] on [Date of Service] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Present:** [e.g., "Patient alone" / "Patient with wife, Pauline"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Reason for Visit:** [Presenting complaint / Follow-up reason] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Consent - AI Scribe:** Informed consent obtained for AI Scribe use (secure, clinician-reviewed, for record accuracy). **Consent - Chaperone:** [Chaperone Offered & Accepted / Offered & Declined / Requested & Present]. Details: [Name & Staff Designation if present]. (Only include if "chaperone" or "intimate exam" is explicitly mentioned in transcript or context, else omit section entirely.) **2. Subjective Assessment** **History of Presenting Complaint:** [Detailed narrative of the history, including symptoms and functional impact] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Patient's Perspective (ICE):** **Ideas:** [Patient's beliefs about the cause of their symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Concerns:** [Patient's specific worries or fears] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Expectations:** [What the patient hopes to achieve from the consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (If no specific points are mentioned, insert: No specific ideas, concerns, or expectations were voiced.) **Social Context & Determinants (MMM5 Context):** **Occupation & Environment:** [e.g., Job type, physical demands, housing] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Supports & Logistics:** [e.g., Carer availability, transport barriers, family support] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Lifestyle & Vulnerabilities:** [e.g., Substance use, diet, financial stressors, literacy barriers] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **3. Objective Assessment** **Background Data Review:** **Contextual Notes:** [e.g., "Patient summary from Best Practice, dated [Date], was reviewed." OR "No contextual notes were available for this consultation."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Correspondence/Reports:** [Note specific documents reviewed.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Pathology/Imaging:** [List key results or relevant recent investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Medical & Medication History:** **Past Medical History:** [List of past medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Current Medications:** [List of regular and PRN medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Allergies:** [List all allergies, or write "Nil Known"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Examination Findings:** Following an explanation of its purpose, consent was obtained for physical examination: [Macro-driven examination section OR manually dictated findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If no examination is mentioned, state "No physical examination was performed during this consultation.") **4. Clinical Synthesis & Risk Formulation** **Summary Statement & Problem List:** **Summary:** [Concise summary of clinical situation and reason for visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Diagnoses:** **[SNOMED-CT-AU full descriptive diagnosis]** ([Provisional / Confirmed]) (Only include if explicitly mentioned in transcript or context, else omit section entirely.) ICD-10-AM: [Full ICD-10-AM descriptive text] (Only include if SNOMED diagnosis is within ICD-10 Chapter V) **Clinical Reasoning & Risk Assessment:** **Rationale for Working Diagnosis:** [Explain clinical reasoning] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Exclusion of Serious Pathology:** [e.g., "CT scan excluded facial fracture."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Assessment of Severity & Clinical Risk:** [Detail relevant risks, e.g., risk of deterioration, complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **5. Problem-Oriented Management Plan** **Shared Decision Making & Education:** **Collaboration:** The management plan was developed in collaboration with the patient. **Understanding Confirmed (Teach-Back):** The patient demonstrated understanding of the key aspects of the plan. **1. [Problem 1 Name from Diagnosis List]** **Goal:** [Clinical and functional goal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Diagnostic Actions:** **Investigations:** [Investigation name]. **Clinical Question:** [Clinical rationale] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Only include the following if risk/benefit/alternatives discussed) Risks, benefits, and alternatives were discussed. **Referral:** [Referral type]. **Reason:** [e.g., "Specialist opinion for diagnosis clarification."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Therapeutic Actions:** **Medication:** [Drug name, dose, frequency, and rationale] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Non-Pharmacological / Procedural:** [Physical therapies, education, wound care, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Monitoring & Observation:** **Plan:** [Specify what is being monitored and why] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Review:** [Timeframe and reason for review] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Repeat this structure for each additional diagnosis and management item.) **6. Overall Follow-up & Safety Netting** **Safety Netting (Condition-Specific):** Patient advised to seek urgent review for the following specific symptoms: - [Symptom 1] - [Symptom 2] - [Symptom 3] The appropriate pathway for seeking urgent care was reinforced (Clinic, Mansfield UCC, 000). **Follow-up Plan:** [Specify timing, location, and purpose of follow-up] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (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 included 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.)