Scribe BC - Pediatric otolaryngology clinic

**Diagnosis:** 1. [describe the most relevant diagnosis or working impression for this consultation] (Only include if a diagnosis or working impression is explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a single line. If diagnosis is uncertain, describe the probable or working diagnosis. ICD-9 code may be included if provided.) 2. [describe the second diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) 3. [describe the third diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) (This diagnosis section is positioned at the top for readability, but reflects conclusions made at the end of the consultation. It may include new or existing diagnoses, depending on relevance to this visit. Typically, only one primary diagnosis is listed.) **Plan:** 1. [outline the first point of the plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) 2. [outline the second point of the plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) 3. [outline the third point of the plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) 4. [outline the fourth point of the plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) (Include this section only if a plan was discussed during the consultation. This section may include follow-up arrangements, investigations, referrals, surgery bookings, or management strategies. If surgery is planned, specify the procedure, admission type (day case or inpatient), urgency, location, estimated length of stay, pooled or short-notice list status, and any prioritisation.) **History:** I was delighted to meet this [insert age] year old [insert gender/identity descriptor] with their [insert accompanying person] in the [insert clinic type, e.g., pediatric otolaryngology (ENT) voice clinic] today, [insert date of appointment]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) They were referred to us because of [insert referral reason, known diagnosis, or presenting concern]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (If this is a follow-up, begin instead with: "I was pleased to see again this [insert age] year old…") [document the patient's demographic information, appointment context (new/follow-up), and a detailed account of the presenting complaint including symptoms, duration, triggers, severity, treatment responses, progression, associated features, and parental observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences using a chronological and narrative clinical tone.) [Mention duration, timing, location, quality, severity and/or context of complaint, if relevant and mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Progression: describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Previous episodes: detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Associated symptoms: any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Relevant previous medical history:** [document any relevant past medical history, including birth history and any specific medical events] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Relevant previous surgical history:** [document any relevant past surgical history. Avoid duplicating details already documented above.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Birth History:** [document birth history details including gestational age, delivery complications, or NICU stay] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **History of intubation:** [document history of intubation including duration, timing, reason, and any associated complications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Allergies:** [document any known allergies to medications or otherwise] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Relevant medications:** [document any relevant medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Relevant Family History:** [document any relevant family medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) **Examination Findings:** General: [document general observations related to patient appearance, overall condition, and any breathing concerns or stridor] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) Ear/otoscopy: [document findings from ear/otoscopy examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line. Comment specifically if microscopy or ear endoscopy was performed) Nose: [document findings from nose examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) Flexible naso-laryngoscopy: [document findings from flexible naso-laryngoscopy examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) Oropharynx: [document findings from oropharynx examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) Neck: [document findings from neck examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) (Include this section only if examination findings are documented. Each item should be written on its own line in the format shown, using full sentences if needed.) **Investigations:** - [Completed investigations with results] (Only include if completed investigations and their results are explicitly mentioned in the transcript, contextual notes or clinical note. Do not include planned or pending investigations; those should be included in the Plan or Recommendations section.) **Impression:** [Summarize the clinical impression, including differential diagnoses and relevant context. Mention any likely or suspected causes, clinical concerns, or pathophysiological reasoning. Use full sentences and write in narrative form. This section may include diagnostic uncertainty. Do not simplify terminology unnecessarily.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Recommendations:** [Outline the next steps in management: investigations to be ordered, referrals, follow-up timing, treatments or instructions for the family. Use full sentences and write in narrative form. Make it clear that the diagnosis and reasons for the recommendations were discussed in detail with the patient and family, that they were given an opportunity to ask questions, and that their questions and concerns were addressed. If alternatives were discussed or declined, this should also be documented.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thank you for this referral. Kind regards, Pediatric Otolaryngology-Head and Neck Surgeon [Insert name of hospital] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely) "This consultation note was generated with the assistance of an AI-based medical scribe. Verbal consent for the use of this technology was obtained from the patient and their parent(s)/guardian(s) at the time of the encounter." **(Instructions for AI output formatting and inclusion logic:** - Avoid short forms (e.g., use "past medical history" instead of "PMHx") - Use only the transcript, contextual notes, or clinical note as a reference - Do not invent or assume any details not explicitly mentioned - Omit placeholders if no relevant information is provided - Maintain full sentences and appropriate clinical tone - Use as many lines or bullet points as necessary to fully capture the information provided**) (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.)