I - Identification:
John Smith, 45-year-old male.
M - Medical Complaint:
Chest pain, onset approximately 30 minutes prior to arrival.
I - Injuries/Information:
No obvious injuries.
S - Signs:
- Response: Alert and oriented.
- Airway: "Patent."
- Breathing: Patient is breathing at a rate of 24 breaths per minute, with slightly labored effort. Auscultation reveals clear lung sounds bilaterally.
- Circulation: Heart rate is 110 bpm, blood pressure 160/90 mmHg. Skin is pale and diaphoretic. Capillary refill is 3 seconds.
- Disability: GCS 15. Blood glucose level is 110 mg/dL. Pain score 8/10.
T - Treatment:
Administered 324mg Aspirin PO. Placed on 12-lead ECG. IV access established in left antecubital fossa. Oxygen administered via nasal cannula at 4L/min.
A - Allergies:
Patient reports no known allergies.
M - Medications:
Patient reports taking Lisinopril 20mg daily for hypertension.
B - Background:
Patient has a history of hypertension. Denies any recent illnesses or hospitalisations. Smokes one pack of cigarettes per day.
O - Other:
Contacted receiving hospital and provided patient report. Patient is requesting pain relief.
I - Identification:
[Patient demographic details] (Only include if explicitly mentioned in transcript, context or clinical note. Include name, age, gender, and any unique identifiers. Provide a brief and succinct response.)
M - Medical Complaint:
[Primary medical complaint or reason for encounter] (Only include if explicitly mentioned in transcript, context or clinical note. Include duration and onset. Provide a brief and succinct response.)
I - Injuries/Information:
[Details of any injuries or other relevant information related to the current presentation] (Only include if explicitly mentioned in transcript, context or clinical note. Include mechanism, location, and severity if applicable. Provide a brief and succinct response.)
S - Signs:
- Response:
[Level of consciousness and responsiveness] (Only include if explicitly mentioned in transcript, context or clinical note. Provide a brief and succinct response.)
- Airway: "Patent."
- Breathing:
[Respiratory status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Include rate, effort, and sounds.)
- Circulation:
[Circulatory status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Include heart rate, blood pressure, skin colour, and capillary refill.)
- Disability:
[Neurological findings or other disability assessments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. May include GCS, temperature, BGL, pain score, RASS, weight.)
T - Treatment:
[Immediate treatments or interventions provided] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Include medications administered, procedures performed, and outcomes. Provide a brief and succinct response.)
A - Allergies:
[Known allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Include medication, food, or environmental allergens.)
M - Medications:
[Current medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Include dosage, frequency, and route.)
B - Background:
[Relevant patient background] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. May include past medical history, social history, or family history pertinent to the presentation.)
O - Other:
[Any other relevant information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. May include patient requests, other observations, or communications with other healthcare providers.)
(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 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.)
