Patient Presents With:
- Main issue(s): [Describe the main issue or reason for the visit as presented by the patient, including the broad concern or request brought to the consultation.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a single line.)
- Other issues addressed: [List any additional issues, concerns or topics that were discussed or managed during the consultation.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a brief list separated by commas.)
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History [Issues - if identified as an issue addressed, include it as its own issue with its own history]:
1. [Problem 1]
- [Describe the timeline and presenting symptoms of Problem 1, including onset, progression and details of the complaint as explained by the patient.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a short paragraph in full sentences.)
- [Detail any relevant associated symptoms linked to Problem 1, including local and systemic manifestations.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.)
- [List any specifically denied or absent symptoms that are clinically relevant to Problem 1.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.)
2. [Problem 2]
- [Describe the timeline and presenting symptoms of Problem 2, including onset, progression and details of the complaint as explained by the patient.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a short paragraph in full sentences.)
- [Detail any relevant associated symptoms linked to Problem 2, including local and systemic manifestations.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.)
- [List any specifically denied or absent symptoms that are clinically relevant to Problem 2.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.)
(Continue with Problem 3, 4, 5, etc. as required)
- [Document the patient's age only if mentioned, and relate it to the context of the presenting issue.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [Summarise current issues, reasons for visit, and descriptions of presenting complaints in context.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a paragraph in full sentences.)
- [Include details of onset, duration, timing, location, quality, severity, and/or context of the complaint.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a paragraph in full sentences.)
- [List aggravating or relieving factors including patient-initiated treatment attempts and their outcomes.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in full sentences.)
- [Describe how symptoms have progressed, including whether they’ve worsened, improved, or fluctuated.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in full sentences.)
- [Detail any previous similar episodes, their timing, management and resolution if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in full sentences.)
- [Describe the impact of symptoms on daily functioning, including work, routine, and activities.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in full sentences.)
- [Include any other focal or systemic symptoms that may accompany the main complaint.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.)
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Systems Review:
- CNS: [Include only positive or explicitly negative CNS symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- ENT: [Include only positive or explicitly negative ENT symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- CVS: [Include only positive or explicitly negative CVS symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Resp: [Include only positive or explicitly negative respiratory symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- GIT: [Include only positive or explicitly negative GIT symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Urinary: [Include only positive or explicitly negative urinary symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Bowels: [Include only positive or explicitly negative bowel symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- MSK: [Include only positive or explicitly negative MSK symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Mental Health: [Include only positive or explicitly negative mental health symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Rheumatology/inflammatory: [Include only positive or explicitly negative inflammatory symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Endocrine: [Include only positive or explicitly negative endocrine symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
- Circulatory: [Include only positive or explicitly negative circulatory symptoms not already covered in the history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in line format.)
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PMHx: [List only past medical history items that are directly relevant to issues discussed in today's consult.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a list.)
Medications: [Document medications if they were updated, changed, started, or specifically discussed, or if relevant to the current history.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a list.)
Allergies: [Include if drug or substance allergies are discussed, whether positive or negative.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a list.)
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Examination:
- Obs: [List any vital sign parameters explicitly mentioned (e.g., BP, HR, RR, Temp, SpO2, Weight).] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a list.)
- [Group all other examination findings under appropriate system subheadings (e.g. CVS, Resp, Abdo, CNS, MSK). Mention every positive and explicitly negative finding as discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in list format under system-specific labels.)
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Investigations: [List any blood tests, imaging, or other investigations that were discussed or ordered. If no investigations were mentioned, omit this section.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a list.)
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Assessment & Plan:
[1. Issue, problem or request 1 (issue, request or condition name only)]
- [State the assessment or working diagnosis for Issue 1.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List differential diagnoses being considered, if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List any investigations planned, pending, or recommended for this issue.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [State treatment initiated or planned, including prescriptions, advice, or procedures.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [Detail any relevant referrals made or discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [Include safety netting information and instructions given to the patient.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
[2. Issue, problem or request 2 (issue, request or condition name only)]
- [State the assessment or working diagnosis for Issue 2.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List differential diagnoses being considered, if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List any investigations planned, pending, or recommended for this issue.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [State treatment initiated or planned, including prescriptions, advice, or procedures.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [Detail any relevant referrals made or discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]
- [State the assessment or working diagnosis for Issue 3, 4, 5 etc.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List differential diagnoses being considered, if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [List any investigations planned, pending, or recommended for this issue.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [State treatment initiated or planned, including prescriptions, advice, or procedures.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
- [Detail any relevant referrals made or discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.)
(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 that the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the relevant placeholder entirely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Never refer to the patient in 3rd person ie. the female, the male. Never refer to me as Dr. Pannu for follow up.)
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"The patient of this consult has consented to use of an artificial intelligence scribe for assistance with this consult, and agrees to recording of the consult for scribe purposes. I, the clinician who has signed this note, have reviewed it and edited it as required."