Urology - New Patient Note

[describe the patient's age, gender, and primary reason for consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not describe this as a follow-up. Write as a single sentence.) [describe whether the patient is accompanied by someone and their relationship to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single sentence.) **Past Medical History:** [document the patient's past medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **Past Surgical History:** [document the patient's past surgical procedures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **External Medications:** [list the patient's current medications, including over-the-counter supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **Known Allergies:** [document any known allergies, specifying type such as drug or environmental] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **Lifestyle Notes:** [document details about the patient's lifestyle, including alcohol use, number of children, marital status, occupation, and smoking status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **Family History:** [document relevant family medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a comma-separated list, indenting subsequent lines.) **History of Present Illness:** [detail the patient's current illness, including onset, progression, symptoms, previous treatments, and relevant diagnostic findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Physical Exam:** [document significant findings from the physical examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single sentence.) **Tests/US Reports:** [describe the results of any tests or imaging reports, including specific findings and interpretations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Impression & Plan:** [provide the clinical impression, current diagnoses, and the detailed management plan including treatment options, prescriptions, patient counselling, and follow-up arrangements, as explicitly stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)