Scribe BC - CST New

Scribe BC - CST New Dear Dr.[referring physician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Thank you for asking us to see [patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) for cardiac assessment. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) CARDIAC DIAGNOSES: [cardiac diagnoses and relevant details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) CARDIAC SURGICAL AND INTERVENTIONAL HISTORY: [history of cardiac surgical and interventional procedures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) NON CARDIAC CO MORBIDITIES: [description of non-cardiac co-morbidities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) MEDICATIONS: [list of current medications, including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a list.) ALLERGIES: [list of known allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a list.) PAST MEDICAL HISTORY: [detailed past medical history, including significant illnesses, hospitalizations, and treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) FAMILY HISTORY: [detailed family history related to cardiac conditions, sudden cardiac deaths, pacemakers, defibrillators, or any other relevant conditions, including the patient's relationship to affected family members] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)Family history is [description of family history for congenital cardiac defects, sudden cardiac deaths, pacemakers and defibrillators in the younger population] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) SOCIAL HISTORY: [description of relevant social history, including living situation, occupation, habits, and lifestyle factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) CLINICAL PRESENTATION: I saw [patient's first name], (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) who is [patient's age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) with [description of patient's current condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) on [current date]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Since the last assessment, [patient's first name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) has remained well with no history of breathlessness with activity or feeding. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The baby is breastfed and finishes within 10 minutes. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There is a history of no increased work of breathing with feeds. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The weight gain has been [description of weight gain]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There is no history of colour change with activity. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) [Patient's first name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) is at day care [description of day care activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) doing all sorts of activities without experiencing chest pain, palpitations or fainting. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Review of systems did not reveal any major issues relevant to cardiac status. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) His immunizations are up to date. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) He to early to have any immunizations. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) PHYSICAL EXAMINATION: [vital signs, including heart rate, blood pressure, respiratory rate, and temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a list.) On examination, [patient's first name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) appeared comfortable and pink in colour. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There were no obvious dysmorphic features seen. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Precordial assessment revealed no evidence of any surgical incisions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The precordium was quiet. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There was no evidence of any heaves or thrills. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Auscultation revealed normal first and second heart sounds. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) I did not appreciate any murmurs or clicks. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There was presence of grade [grade of murmur] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) at [location of murmur]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There was a presence of [description of additional findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) of grade [grade of additional findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) at [location of additional findings]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The abdomen was soft with no evidence of hepatomegaly. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The femoral pulses were well felt. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The capillary refill was less than 2-3 seconds both centrally and peripherally. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There is no evidence of subcostal and intercostal recession. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Air entry was equal to both lung fields. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) There were no wheezing sounds heard. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) INVESTIGATIONS: EKG: A 12-lead EKG revealed sinus rhythm with a heart rate of [heart rate] BPM. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The QRS progression was [description of QRS progression]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) All the measured intervals were [description of measured intervals]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) The QTc interval was [QTc interval] milliseconds. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) ECHOCARDIOGRAM: [findings from echocardiogram] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.) IMPRESSION & PLAN: [patient's first name]'s (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) cardiac status [assessment of patient's cardiac status]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) A further follow-up cardiac assessment [recommendation for follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) is recommended in [timeframe for follow-up]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Activity recommendation: [activity recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) Antibiotic prophylaxis requirement with dental work: [patient's first name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) does not need any antibiotic prophylaxis for dental work up or any other procedure causing bacteremia but maintaining good oral hygiene and regular dental check up is necessary. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **_"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."_** (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.)