Gynaecology Summary Note

Name: [Patient's full name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Patient's age] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Age unknown".) Chief Complaint: [Primary gynaecological concern or reason for visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Not stated". Write as a brief statement.) History of Present Illness: [Detailed description of current gynaecological symptoms, including onset, duration, character, associated symptoms, aggravating and relieving factors, and any recent medical consultations for this issue] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Not stated". Write in paragraphs of full sentences.) Menstrual History: [Menstrual cycle details, including regularity, duration, flow, last menstrual period, age of menarche, menopausal status, and HRT history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Not discussed". Write as a brief statement or list.) Obstetric History: [Pregnancy history, including gravida, para, abortions, living children, and delivery details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use a concise format such as "G2P2".) Gynaecological History: [Previous gynaecological conditions, surgeries, procedures, contraceptive history, and sexual history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Not discussed". Write as a brief statement or list.) Past Medical History: [Relevant medical conditions, surgeries, and hospitalisations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief statement or list.) Family History: [Relevant family medical history, particularly for breast, ovarian, or other cancers, including affected relative, condition, and age at diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a list or short paragraph.) Past Surgical History: [Any previous surgical procedures] (If the transcript explicitly states no previous surgery, write "No previous surgery". If previous surgical history is not addressed in the transcript, contextual notes, or clinical note, write "Previous surgical history has not been discussed".) Medications: [Current medications, including hormonal therapies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Nil".) Allergies: [Known allergies and reactions] (If not explicitly mentioned in transcript, contextual notes, or clinical note, write "Not discussed". If it is explicitly mentioned that the patient has no allergies, write "No known allergies".) Physical Examination: [General appearance, vital signs, abdominal examination, and pelvic examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "To be performed".) BMI: [Body Mass Index] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Assessment: [Document the clinician's explicitly stated clinical impression and differential diagnoses, summarising key findings and history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as a list or short paragraph.) Plan: (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Structure the plan using the subheadings below.) Investigations: [Diagnostic tests ordered, including imaging and laboratory work] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line.) Management: [Treatment recommendations, referrals, and patient advice] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line.) Follow-up: [Instructions for next appointments or future actions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line.)