Scribe BC - CNS med onc treatment note

Identification [describe patient demographics, relevant past medical history, and key diagnostic findings related to their primary condition, including pathology results and previous treatments with dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) [describe the reason for the current visit and who accompanied the patient, including any interpreter details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) **Consent** "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks" steroids: [document current steroid use, including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line of text.) anti-epileptic: [document current anti-epileptic medication use, including dosage, frequency, and any history of seizures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line of text.) Interval History [summarize changes in patient's symptoms, functional status, and overall well-being since the last visit, including any new or resolved issues and their impact on daily life] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) [document the patient's living situation and who they reside with] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) Physical Exam ECOG performance status: [document the patient's ECOG performance status with a numerical score and a description of their functional abilities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line of text.) [describe neurological exam findings, cognition assessment, including speech, extraocular movements (EOM), cranial nerve (CN) assessment, strength, sensation, pronator drift, finger-to-nose (FTN) test, and gait] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) Assessment/Plan [provide a concise assessment of the patient's current condition, linking it to the interval history and physical exam findings, and state the rationale for any current treatment decisions, including whether dexamethasone is indicated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) [detail the proposed treatment plan, including medication name, administration route, dosage, cycle length, potential toxicities, and confirmation of patient consent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) [outline the follow-up plan, including the timing of subsequent appointments and any scheduled imaging or investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph of full sentences.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 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.)