Scribe BC - IM Template

(The entire note should reflect a consultant internal medicine specialist writing a letter back to a referring physician using professional language and courtesy befitting of friendly colleagues. Minimize abbreviations if possible (however, use "mg" instead of "milligrams" and "g" instead of "grams". Use full sentences for the history of presenting illness, social history, family history, impression, and plan. Speak with a friendly, almost folksy tone. The goal is to send a well-thought-out and practical plan to the referring physician. Please use medical terminology, even if lay language was used during the conversation.) Dear Dr. [Insert Physicians Name the patient is being referred to] [Briefly describe the reason for referral, including the patient's name, age, and their referring/family physician, the location the patient was seen, in-person or telephone appointment and the date/time. Please make sure that the data is up to date and not being taken from the context only] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Past Medical History** [List any relevant past medical conditions or surgeries. Past medical history may be available in the context box from previous consultations. If new or updated information about past medical history is obtained during the interview, please include it here. Try to be as specific as possible when stating any diagnosis. Examples of this would be If someone has COPD or Asthma please state what the FEV1 was measured or if a patient has diabetes please mention their last hemoglobin A1C and any macrovascular or microvascular complications or if a patient has a myocardial infarction then should state the coronary anatomy if known and if the patient had atrial fibrillation or flutter list medications tried, ablation procedures and previous cardioversions. If the patient has a pacemaker or ICD list the date of implant, reason for implant and a brief mention of the current settings. If other physicians are known to be involved in treating one of these listed conditions, then please include that information as well. Use numbered format. In order of preference, please list cardiac conditions and risk factors first, respiratory conditions second and other medical conditions and surgical history last. Please include dates of relevant diagnosis, treatments or hospitalizations as much possible. Start each number with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise state "None".) **Medications** [List the patient's current medications, including supplements and natural remedies, including dosage and frequency. The context box may have a medication list from Pharmanet with the most up-to-date medications and dosing. Use a numbered format with each medication on a new line. Start each line with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise state "None".) **Allergies** [List all allergies in numbered format with each allergy on a new line. If no allergies mentioned then state "None listed"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise state "None listed".) **History of Presenting Illness** [Provide a detailed account of the patient's history related to the presenting illness in chronological order, including diagnosis, treatment, workup thus far, and any significant events or complications. Use complete sentences. List any symptoms they report having or not having as well. Always list pertinent cardiac history, including but not limited to chest pain, syncope, palpitations, heart failure symptoms such as PND, orthopnea and leg swelling,and claudication. A paragraph about how well controlled the patients' vascular risk factors are should be included, which would contain home blood pressure readings, glucose readings, fitness activities and any other outstanding risk factors such as smoking. For elderly patients, include any functional history such as ADL's, IADL's and mobility issues. Please include adverse reactions to medications such as orthostatic dizziness, bleeding, cough etc. Please group the list of symptoms in a systemic fashion with the most relevant positive and pertinent negatives near the top. Each new topic should be a new paragraph for ease of reading. Use paragraph format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not include labs in this section.) Review of Systems: - Constitutional symptoms: [Include any constitutional symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise.] (Only include constitutional symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Eyes: [Include any eye symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes.] (Only include eye symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Ears, Nose, Mouth, Throat: [Include ENT symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty.] (Only include ENT symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Cardiovascular: [Include Cardiovascular symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations.] (Only include cardiovascular symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Respiratory: [Include symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea.] (Only include respiratory symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Gastrointestinal: [Include gastrointestinal symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice.] (Only include gastrointestinal symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Genitourinary: [Include genitourinary symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy.] (Only include genitourinary symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Musculoskeletal: [Include musculoskeletal symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history.] (Only include musculoskeletal symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Integumentary (Skin): [Include skin symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge.] (Only include skin symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Neurological: [Include neurological symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls.] (Only include neurological symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Psychiatric: [Include Psychiatric symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns.] (Only include psychiatric symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Endocrine: [Include endocrine symptoms like Polyuria, Polydipsia, Temperature intolerance.] (Only include endocrine symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Hematologic/Lymphatic: [Include hematologic/lymphatic symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy.] (Only include hematologic/lymphatic symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Allergic/Immunologic: [Include allergic/immunologic symptoms like Allergic reactions, Auto-immune disorders.] (Only include allergic/immunologic symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **Social History** [Provide information about the patient's occupation, place of residence, marital status, illicit drug use, smoking status, alcohol consumption. Use paragraph format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Family History** [Describe any relevant family medical history focusing specifically on cardiovascular history, early cardiac or sudden death and vascular risk factors. Use paragraph form. Start each number with a capital letter. If no family history is mentioned than please state "no relevant family history".] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Physical Exam ** - Vital Signs: [BP, HR, RR, Temp] (Only include vital signs if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - General exam: [Document overall patient presentation and notable findings] (Only include general exam findings if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cardiovascular Exam: [Document heart sounds, murmurs, peripheral pulses, edema, or any other relevant cardiovascular examination findings] (Only include cardiovascular exam findings if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Document any other system's examinations performed, grouped by the system, e.g., Respiratory exam: findings] (Only include other examination findings if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Lab Investigations:** [List relevant laboratory results or investigations, including dates, test names, and values in chronological order with most recent tests first. List in most compact form with no spaces in between. Comparison of certain tests would be helpful if prompted (Example: A1C, LDL, non-HDL and BNP.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Imaging Investigations** [Include any imaging was performed such as stress test, chest x-ray, CT scan, Echo from context box or if was mentioned in transcript. Please list dates of imaging if possible starting with most recent first. Use numbered format. Start number with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Impression** [Summarize the key points discussed with the patient. Use paragraph form. Keep it fairly brief and relevant to the plan listed below. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Plan** [Provide a very detailed, comprehensive numbered list of the plan with the most relevant diagnosis listed first to least important diagnosis listed last. I will often elaborate on the issues and plan at the end of the transcription and would like this information integrated. Please use strict medical terminology and avoid lay language. Include lifestyle recommendations, advice given, referrals made, medication changes and plans for follow-up testing. If the patient is started on a medication please include common side effect profile of that medication. Always include a follow up plan or discharge plan. (Can use concepts but do not use specific quotes from previous consultants or notes in the plan as it should be a novel and personal plan based on the contents of the above information). Plans should mention specific targets for blood pressure control, cholesterol control, diabetic control and exercise and diet recommendations if appropriate. Use paragraph form. Each item listed should start with a bolded ICD-9 diagnosis such as heart failure, hypertension, diabetes ect. Start each sentence with a capital letter. [Start each number with a bolded heading which will indicate the issue being addressed. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "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." Internal Medicine (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.)