General Paeds Consult Medical Report

Re: [Patient full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), [Patient age] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) years old (DOB: [Patient date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)) Address: [Patient address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on one line separated by commas.) Hospital Number: [Patient hospital number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Seen on: [Date of consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) With: [Relationship of the person accompanying the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. State only the relationship, not the accompanying person's name.) Clinician: [Clinician name and title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Name of referring GP or confirmation of self-referral] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Email address of referring GP] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Address of referring GP] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on one line separated by commas.) Problem List: 1. [Numbered list of current problems or explicitly stated diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not invent or infer diagnoses.) Medications: 1. [Numbered list of current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Discontinued Medications: 1. [Numbered list of discontinued medications and brief reason for stopping where relevant] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Presenting Complaint: [Main concern or reason for the patient's attendance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) History of Presenting Complaint: I had the pleasure of reviewing [Patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) who is now [Patient age in years] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.). [Patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) attended with [relationship of accompanying person] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.). [Detailed narrative of the current illness including onset, duration, frequency and progression of symptoms, impact on the patient's functioning, efficacy of any treatments or interventions, any behavioural challenges including suspensions or aggression, anxiety at school where applicable, and any supports currently being received] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences. When attributing information, use the patient's name or the relationship of the accompanying person, not the accompanying person's name.) [Summary of the patient's home life and any relevant issues, including aggression or anxiety at home, ability to complete homework or participate in extracurricular activities, and any parental stress] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences. When attributing information, use the patient's name or the relationship of the accompanying person, not the accompanying person's name.) [Involvement of other physicians and allied health therapists including the frequency of visits, goals of therapy, name of therapist and location] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) ROS: [Systematic review of body systems including any positive and negative findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Birth History: [Details of the patient's birth including gestational age, delivery method and any complications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Past Medical History: [Previous medical conditions and their current status, including any accidents or injuries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Past Surgical History: [Previous surgical procedures and any associated complications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Immunisations: [Vaccines the patient has received] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Allergies: [Known allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Family History: [Relevant medical history of family members] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Social History: [Patient's living situation, family structure and relevant socioeconomic factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Diet: [Patient's current dietary intake and feeding regimen] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If diet details have already been described in the History of Presenting Complaint section, print: "As detailed in History of Presenting Complaint".) Development: [Patient's developmental milestones and bonding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Physical Exam Vitals: [Vital signs including temperature, pulse, respiratory rate, blood pressure and oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Growth Parameters: [Measurements of weight, height and head circumference with percentiles] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Physical examination findings for each body system examined] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Labs: [Laboratory test results with date and time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Diagnostic Imaging: [Imaging studies performed and their results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Assessment: [Summary of the patient's condition and likely diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: 1. [Numbered list of treatment plans, interventions and follow-up actions for each identified issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Summary: [Decision regarding patient care and the justification for that decision] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Kind Regards, [Clinician full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Clinician title and specialty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) cc: Parents: [Parent or guardian email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) (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 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.)