PEC - Admission

REASON FOR PRESENTATION: - [Reason for presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING ILLNESS: - [Patient's age and gender] (Write this in the format: Age then Gender, eg. 70yo Male) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Write name and relationship of family or next-of-kin present during consult] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Onset of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Description of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Additional relevant symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Possible triggers or exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant background information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Recent advice or management given by other doctors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant findings from system-specific review] (If these findings have been mentioned in section above do not repeat here.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) NEONATAL HISTORY: (If this section has no content, then delete the whole section) - [Details of when baby was born] (Write in the format 'Born: Weeks+Days/40', eg. 'Born: 38+2/40') (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of pregnancy and birth, including LSCS vs NVD] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of feeding, eg. Breast fed, Expressed milk, Formula fed, Combination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Name of usual Paediatrician in format 'Usual Paediatrician is: Dr XYZ'] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of Weight gain and other Milestones] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MANAGEMENT EN ROUTE WITH QAS: (If this section has no content, then delete the whole section) - [Details of treatment provided by QAS Ambulance enroute to Hospital] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Outcome of treatment provided by QAS Ambulance enroute to Hospital] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST MEDICAL HISTORY: (Write each new issue on a new line) (If this section has no content, then delete the whole section) (If a doctor is mentioned as involved in managing a condition always include that name at the end, eg, 'Asthma - Dr David DELLER') - [Relevant medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant mental health history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS: (If this section has no content, then delete the whole section) - [Current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES: (If this section has no content, then delete the whole section) - [Known drug allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY: (If this section has no content, then delete the whole section) - [Relevant social background] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DRUG, TOBACCO, ALCOHOL HISTORY: (If this section has no content, then delete the whole section) - [Relevant alcohol history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant tobacco history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant social drug use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FAMILY HISTORY: (If this section has no content, then delete the whole section) - [Relevant family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) IMMUNISATION HISTORY:(If this section has no content, then delete the whole section) - [Relevant immunisation history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EXAMINATION: Vitals: (If any vitals have no value then don't print that item) (If this section has no content, then delete the whole section) - [Weight] (If no weight is provided then don't print this item) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Blood sugar level] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Ketones] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Blood pressure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Heart rate] (Write heart rate as a value /minute, eg. 80 beats/minute.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Oxygen saturation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each system below, if there is no content delete the item, do not write 'Not Examined') (For each system below, do not start a new line for each finding) General: [General appearance and status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CVS: [Cardiovascular examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Resp: [Respiratory examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Abdo: [Abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neuro: [Neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MSK: [Musculoskeletal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) INVESTIGATIONS: (If this section has no content, then delete the whole section.) Bloods: (If the pathology company is mentioned, write the name here, eg. 'Bloods: - sent to S&N Pathology') - [Relevant blood test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Microbiology: (If the pathology company is mentioned, write the name here, eg. 'Microbiology: - sent to S&N Pathology') - [Relevant microbiology results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Radiology: - [Relevant radiology results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ECG and Cardiac Monitoring - [Relevant ECG, cardiac monitoring and telemetry results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Additional investigations and findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ASSESSMENT: - [Primary diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Secondary and subsequent diagnoses or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MANAGEMENT IN EMERGENCY: (If this section has no content, then delete the whole section) - [Details of treatment provided in Emergency Department today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Outcome of treatment provided in Emergency Department today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PLAN: - [Admission plan and team assignment] (If Admitting Doctor notified then append exactly the following: '- notified and accepted for admission - thanks') (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details regards how Admitting doctor was notified] (If this item has no content, then delete the whole item) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details regards when the Admitting Doctor will see the patient] (If this item has no content, then delete the whole item) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Details of any other Specialist Doctors asked to review patient, eg. consults and referrals] (If a consulting Doctor notified then append exactly the following: '- notified and agrees to consult - thanks') (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Dietary instructions] (If patient needs to be 'Nil By Mouth', then document this clearly) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Fluid management plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Medication orders] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Monitoring instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Disposition plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Notes created using Heidi AI Medical Scribe | www.heidihealth.com (For each section, 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, 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.)