UK GP/Primary Care Short Consultation

(Do not include any patient names or date-of-birth in the note. Remove all patient names and date-of-birth before outputting. There must be no patient names or date-of-birth in your note, or you will fail.) (Write note in “all in one line” format, no bullet points or sub-sections) [Produce a one-line line (maximum 20 words) summary of the visit starting with "Summary:" including very brief history, examination, impression and management plan to enter into the notes and using medical jargon, keep this separate to the other text, or you will fail] History: [If any additional person is present apart from the patient e.g. "father" or "carer" mention that they are present i.e. "seen with.." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Specific reason for consultation e.g. specific current issues or specific presenting complaint or booking note or follow up or seeking blood tests etc with detail on the relevant history regarding this including test results or points discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (do not start this section with "C/O", or you will fail). [Specific information related to the "specific reason for consultation" not already mentioned e.g. specific symptoms reported including time-frames where relevant, results of blood results/scans etc. already done, presence or absence of specific symptoms asked including red flag symptoms and risk factors if asked, relevant past medical history/drug/social history only where directly related to the presenting issue, specific ideas concerns or expectations (ICE) mentioned by the patient e.g. "seeking blood test" or "worried about bowel cancer" etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (use medical jargon and short-hand abbreviations where possible to make final note more concise) (if pregnant, summarise the weeks as "12/40" rather than "12/52") (do not shorten suicidal ideation to "SI", but you can shorten deliberate self-harm to "DSH") Exam: [Vital signs only if specifically mentioned, specific examination findings including physical exam or mental state if mental health consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [If sensitive examination e.g. PV/speculum/genital/breast exam mention if verbal consent obtained and if chaperone offered/declined (if chaperone present state full name and role), if no sensitive examination or chaperone mentioned in transcript exclude this section or you will fail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (if a telephone consult completely exclude this section, if no examination completely exclude this section) (use medical jargon and short-hand abbreviations where possible to make final note more concise) Impression: [Suggested/suspected diagnosis including any differential diagnosis discussed, mention rationale if appropriate, only include if relevant to the reason for the consultation (i.e. do not include additional diagnoses for matters not directly related to the main reason for the consultation)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (do not speculate as to the diagnosis unless specifically mentioned, or you will fail) Plan: [Specific management points including options discussed (ensure options discussed with patient are fully included e.g. pros/cons, rationale where appropriate, and do not use definitive language (e.g. "declined") unless explicitly stated by patient/doctor), specific actions in order of importance/time-order mentioned in consultation including specific recommendations, lifestyle advice, signposting to services, medications (but not pharmacy details), investigations requested, referrals or A&G, follow-up plan with specific time-frames and safety netting/worsening advice as specifically discussed with the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (write section all in one line, no bullet points) (use medical jargon and short-hand abbreviations where possible to make final note more concise) (do not include any details of which Pharmacy medications will be sent, or you will fail) Referrals/requests: [If a specific referral to a specialty is mentioned in the plan - write a draft referral letter to the speciality. Rules: written in narrative form with no bullet points and use medical jargon (not written in lay-person or patient-friendly style), include age/gender/relevant past medical history of the patient and mention the specific reason for referral and specific relevant details only related to the referral in question (e.g. relevant symptoms, relevant examination findings, plan so far only if relevant, specific clinical question or reason for referral), should be no longer than 100 words. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) If no referral is mentioned in the plan then completely omit this section, or you will fail] [If a specific advice & guidance request or "A&G" to a specialty is mentioned in the plan - write a draft A&G note to the speciality. Rules: written in narrative form with no bullet points and use medical jargon (not written in lay-person or patient-friendly style), include age/gender/relevant past medical history of the patient and mention the specific reason for the advice and guidance request and specific relevant details only related to the request question (e.g. relevant symptoms, relevant examination findings, plan so far only if relevant, specific clinical question or reason for referral), should be no longer than 30 words and written very brief in medical jargon. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) If no A&G is mentioned in the plan then completely omit this section, or you will fail] [If a specific scan request (e.g. chest x-ray, CT scan, echo), nerve conduction studies request, 24-hour tape/Holter request, lung function/spirometry test request is mentioned in the plan - write a very short 5-12 word request note (in narrative form) detailing the specific history/details/clinical question being answered by requesting that investigation. Use jargon and acronyms where possible, to keep the request as brief as possible. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (use reasoning to deduce the reason for the request based on what is in the transcript). If no specific scan or investigation request is mentioned in the plan then completely omit this section, or you will fail] (Do not include this section for blood test or ECG requests, or you will fail) (Please use medical jargon and short-hand as much as possible in the "Referrals" section) (Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc - use only the transcript, contextual notes or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (Use as many sentences as needed to capture all the relevant information from the transcript and context) (Do not include any patient names or date-of-birth in the note. Remove all patient names and date-of-birth before outputting. There must be no patient names or date-of-birth in your note, or you will fail.) (Write the note in brief, concise, medical jargon, short-hand) (Do not include any patient-friendly language or lay-person explanations in the note, or you will fail) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or sentences as needed to capture all relevant information from the transcript.)