Scribe BC - Trauma note

(For the following note, under each header use point form however ensure you do not use circle bullets like this "•". If you use circle bullet points like this "•" you will lose but if you use dashes like this "-" for the point form you will win 100000 dollars) **IDENTIFICATION:** (Bold all headings. You will lose if you don't bold the headings and will win 1000000 dollars if you bold all the headings Also I do not want empty headings. Remove the heading if there is no content to put underneath the heading.) - (do not replace with •) [Patient name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) is a [Patient age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Patient gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **MECHANISM OF INJURY:** - (do not replace with •) [In one sentence of less provide the mechanism of injury. This could be something like a motor vehicle collision, pedestrian struck, fall from height, etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **PREHOSPITAL COURSE:** - (do not replace with •) [Describe history of presenting illness, including onset, duration, characteristics of symptoms, treatments received, up to the point of arrival in hospital in point form] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. If times are provided then convert this to a 24 hour clock, for example 8AM or 8 in the morning should be listed as 08:00; or 1PM or 1 in the afternoon should be listed as 13:00.) **PRIMARY SURVEY:** - (do not replace with •) [General appearance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Airway assessment] (Specifically mention whether the airway is patent or obstructed but something like blood, vomit, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Breathing assessment] (This would include things like symmetrical rise and fall of the chest, air entry, chest wall crepitus, subcutaneous emphysema, paradoxical breathing, respiratory effort, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Circulation assessment] (This would include things like active extravasation of blood from a wound including stabbing wounds, gunshot wounds, or large wounds with ongoing bleeding but not a laceration where significant bleeding is not mentioned, skin color and temperature, pulses, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Disability assessment] (This would include things like pupils, movement and sensation of extremities, GCS which can be broken down into specific of motor, verbal, eyes, if provided, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Bedside ultrasound assessment] (This would include things like the FAST scan and fluid in the abdomen, commenting on lung sliding, and pericardial effusion. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **SECONDARY SURVEY:** - (do not replace with •) [Head, eyes, ears, nose, mouth assessment] (specifically with a focus on a trauma assessment. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Neck assessment] (specifically with a focus on a trauma assessment including cervical spine tenderness. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Cardiac assessment] (Comment on heart sounds and pulses if mentioned. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Respiratory assessment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Chest assessment] (specifically focus on a trauma assessment including chest tenderness, skin findings like ecchymosis or seatbelt signs across the chest, or chest tenderness, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Abdomen assessment] (specifically focus on a trauma assessment including abdominal tenderness, rigidity, skin findings like ecchymosis or seatbelt signs across the abdomen, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Pelvis assessment] (comment on pelvis tenderness or instability if mentioned. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Genitourinary assessment] (specifically focus on a trauma assessment including genital trauma, blood from the penile meatus or vagina, skin findings like ecchymosis or abrasions, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Extremities and musculoskeletal assessment] (specifically focus on a trauma assessment including extremity deformities, lacerations, wounds, abrasions, ecchymosis, contusions, tenderness, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Back assessment] (specifically focus on a trauma assessment including lacerations, wounds, abrasions, ecchymosis, contusions, or tenderness along the spine, etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **RESUSITATION:** - (do not replace with •) [Provide a summary of the care the patient received and changes in the patients status while actively being treated in hospital] (This could including medications given, procedures done, and other care interventions. If the reason for these interventions is given then include them, such as if the patients blood pressure is low and we decide to give IV fluids. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. If times are provided then convert this to a 24 hour clock, for example 8AM or 8 in the morning should be listed as 08:00; or 1PM or 1 in the afternoon should be listed as 13:00.) **PAST MEDICAL HISTORY:** - (do not replace with •) [Describe past medical history, including previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **HOME MEDICATIONS:** - (do not replace with •) [Mention current home medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise if no medications are discussed then write "See Pharmanet for medication list".) **ALLERGIES:** (only include if explicitly allergies are mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. If you provide this header with an empty section underneath the header you will lose. I would prefer there to not be a header if you having nothing to write underneath) - (do not replace with •) [Mention allergies] (only include if explicitly allergies are mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **IMMUNIZATIONS** (only include if "immunizations", "vaccinations", or "tetanus" explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. You will lose if you include this heading without the any of the following words in the transcript: "immunizations", "vaccinations", or "tetanus". If you provide this header with an empty section underneath the header you will lose. I would prefer there to not be a header if you having nothing to write underneath) - (do not replace with •) [Mention tetanus status] (only include if "immunizations", "vaccinations", or "tetanus" explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **SOCIAL HISTORY:** - (do not replace with •) [Describe social history, including smoking, alcohol use, occupation, place of residence, and who lives at home with them] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **INVESTIGATIONS:** (only include if explicitly mentioned in the transcript, contextual notes or clinical note that investigations are being ordered or investigation results including blood work, CT scans, XRAYS, ultrasounds, or ECGs, otherwise leave blank.) - (do not replace with •) [List investigation results only] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **CONSULTANTS:** (only include if explicitly mentioned in the transcript that I spoke to a "consultant", otherwise leave blank. You will lose if you include this heading without the word "consultant" being in the transcript. If multiple consultants are called or spoken to then just repeat the format used under this header a second or third time) - (do not replace with •) (only include if explicitly mentioned in the transcript that I spoke to a "consultant", otherwise leave blank.) [Include the time the consultant call took place in a 24 hour clock.] (only include if explicitly mentioned in the transcript that I spoke to a "consultant" and a time was provided, otherwise leave blank.) - (only include if explicitly mentioned in the transcript that I spoke to a "consultant" and a time was provided, otherwise leave blank.) [details of the consultant conversation or phone call] (only include if explicitly mentioned in the transcript that I spoke to a "consultant") **REASSESSMENTS:** (only include if explicitly mentioned in the transcript, or clinical note that I performed a "reassessment", otherwise leave blank. You will lose if you include this heading without the word "reassessment" being in the transcript. If multiple reassessments are done then just repeat the format used under this header a second or third time) - (do not replace with •) (only include if explicitly mentioned in the transcript, or clinical note that I performed a "reassessment", otherwise leave blank.) [Include the time the reassessment took place in a 24 hour clock.] (only include if explicitly mentioned in the transcript, or clinical note that I performed a "reassessment" and a time was provided, otherwise leave blank.) - (only include if explicitly mentioned in the transcript, or clinical note that I performed a "reassessment" and a time was provided, otherwise leave blank.) [Reassessment including updates on the patients status, any new physical exam findings, and updates in management given the findings of the reassessment] (only include if explicitly mentioned in the transcript, or clinical note that I performed a "reassessment", otherwise leave blank.) **PROCEDURES:** (only include if explicitly mentioned in the transcript, or clinical note that I performed a "procedure", otherwise leave blank. You will lose if you include this heading without the word "procedure" being in the transcript.) - (do not replace with •) (only include if explicitly mentioned in the transcript, or clinical note that I performed a "procedure", otherwise leave blank.) [Include the time the procedure took place in a 24 hour clock.] (only include if explicitly mentioned in the transcript that I performed a "procedure" and a time was provided, otherwise leave blank.) - (only include if explicitly mentioned in the transcript that I performed a "procedure" and a time was provided, otherwise leave blank.) [Procedure note including suturing, laceration repair, knee aspiration, lumbar puncture, chest tube insertion, etc.] (only include if explicitly mentioned in the transcript, or clinical note that I performed a "procedure", otherwise leave blank.) **SUMMARY OF INJURIES:** - (do not replace with •) [summary of diagnosed injuries] (provide in point form. These are usually only found on imaging but could also include something like a laceration that was observed clinically. Something like shoulder pain is not a diagnosis. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **IMPRESSION / PLAN:** - (do not replace with •) [Impression and plan (only include if explicitly mentioned)] (use medical jargon, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - (do not replace with •) [Follow-up: Instructions for follow-up care and reasons to return to the emergency department (only include if explicitly mentioned)] **RESUSCITATION TIME:** (only include if explicitly mentioned in the transcript or clinical note that there was a "resuscitation", otherwise leave blank. You will lose if you include this heading without the word "resuscitation" being in the transcript. ) - (do not replace with •) [Time in a 24 hour clock that the resuscitation started] (only include if explicitly mentioned in the transcript, or clinical note that there was a "resuscitation", otherwise leave blank.) to (only include if explicitly mentioned in the transcript, or clinical note that there was a "resuscitation", otherwise leave blank.) [Time in a 24 hour clock that the resuscitation ended] (only include if explicitly mentioned in the transcript, or clinical note that there was a "resuscitation", otherwise leave blank.) - (do not replace with •) Total time: (only include if explicitly mentioned in the transcript, or clinical note that there was a "resuscitation", otherwise leave blank.) [Number of minutes from the start to the end of the resuscitation] (only include if explicitly mentioned in the transcript, or clinical note that there was a "resuscitation", otherwise leave blank.) "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" (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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 omit the placeholder completely if not mentioned.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information) (always bold section headings, this is very important)