Paeds ED Template

Presenting Complaint and Background: [presenting complaint and relevant background] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Past Medical History: [patients past medical history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Drug History: [current medications including regular, PRN, and OTC] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Allergies: [patients allergies and reactions if stated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Social History: [patients social history including living situation, family members, occupation/schooling if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs.) Paediatric History: [birth history including gestational age and mode of delivery] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short bullet points.) [immunisation history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short bullet points.) [developmental milestones and growth] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short bullet points.) Observations and Examination: [general observations including consciousness, alertness, and GCS] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) [chest examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) [cardiac examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) [abdominal examination findings including tenderness, bowel sounds, and specific signs such as Murphy’s or Rovsing’s] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) [peripheral findings including perfusion, pulses, temperature, capillary refill] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Impression: [initial clinical impression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Investigations: [results and findings from bloods, imaging, or other investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Diagnosis: [working or confirmed diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Interventions and Actions: [actions taken, procedures performed, and interventions given] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Plan: [management plan including further investigations, treatments, monitoring, and follow-up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) (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 include 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.)