Subjective:
- Follow up for previously discussed condition.
- ICE: Patient's ideas are that the pain is getting worse, concerns are that it is something serious, expectations are to get pain relief.
- Current issues: Patient presents with increased pain in their left knee, which started after a fall while walking on the beach in Bundoran. The pain is described as a sharp, throbbing pain, worse with weight-bearing.
- Past medical history: Nil.
- FH: Mother with a history of osteoarthritis.
- SH: Lives alone, works as a teacher in Sligo, non-smoker, drinks alcohol socially, no illicit drug use.
- Medications: Ibuprofen 400mg as needed for pain.
- Allergies: NKDA.
Objective:
- Physical examination: Left knee examination revealed swelling, tenderness to palpation over the medial joint line, and a reduced range of motion. No effusion noted.
- Vital signs: BP 130/80 mmHg, HR 78 bpm, RR 16, Temp 36.8°C.
- Chaperone: Patient declined a chaperone.
Assessment:
1. Left knee pain.
- Assessment: Likely meniscal tear.
Plan:
1. Investigations planned: X-ray of the left knee.
- Treatment planned: Continue Ibuprofen for pain relief, advise rest and ice.
- Relevant referrals: Referral to physiotherapy.
- Patient has given consent for AI transcription using Heidi AI for the consultation. Heidi AI is GDPR compliant.
(Use Hiberno (Irish) English spellings for all spellings including placenames, proper nouns and medications. Focus on the West of Ireland and the North-West in particular for placenames.)
(Do not use profanity even if mentioned during the consultation.)
(Any relevant past medical history, family history or social history should be listed underneath the relevant issue/problem, not in its own section.)
(Do not give medical advice or interpret medical findings.)
(Include subjective, objective, assessment, and plan of action in all Heidi Notes.)
Subjective:
- [State if consultation is a new problem or a follow up for a previously discussed condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [ICE: Patient's Ideas, Concerns and Expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current issues, reasons for visit, history of presenting complaints etc (if applicable), use bullet points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Past medical history, previous surgeries (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [FH: Relevant family history (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [SH: Social history i.e. lives with, occupation, smoking/alcohol/drugs, recent travel, carers/package of care (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medications (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Social history (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergies (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [Physical or mental state examination findings, including vitals and system specific examination, if specific tests are mentioned add in, including their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations with results] (You must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Vital signs listed, e.g. T, Sats %, HR, BP, RR, (as applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [If the patient has been offered a chaperone please include same and their decision on same] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[1. Issue, problem or request 1 (issue, request or condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Assessment, likely diagnosis for Issue 1 (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis for Issue 1 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[2. Issue, problem or request 2 (issue, request or condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Assessment, likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis for Issue 2 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis for Issue 3, 4, 5 etc (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[1. Investigations planned for Issue 1 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Treatment planned for Issue 1 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant referrals for Issue 1 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[2. Investigations planned for Issue 2 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Treatment planned for Issue 2 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant referrals for Issue 2 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[3. Investigations planned for Issue 3, 4, 5 etc (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Treatment planned for Issue 3, 4, 5 etc (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant referrals for Issue 3, 4, 5 etc (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Comment on whether patient has given consent for AI transcription using Heidi AI for the consultation. Always state GDPR compliance of Heidi AI] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript or context; otherwise omit the 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.)
