(the whole document should be plain text, no bullets. detailed with a few quotes in the subjective section as needed to indicate quality of sensation and pain)
SUBJECTIVE
[Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PAST MEDICAL HISTORY
[Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
[Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
ALLERGIES
[note any allergies in this section. one line per item, followed by reaction. plain text, no bullets]
SUPPLEMENTS
[list current supplements and doses, date started. one item per line. no bullets]
[list past supplements, doses, dates started and dates discontinued. plain text, no bullets]
PRESCRIPTION MEDICATIONS
[list current medications and doses, date started. one item per line. no bullets]
[list past medications, doses, dates started and dates discontinued]
LABS AND INVESTIGATIONS
[list lab results as uploaded from pdf and dictated. Results should be entered by date in reverse chronological order. plain text. one lab result per line. no bullets. Include reference ranges where applicable. For anything out of lab range, bold the entire finding and mark H for high, L for low]
[add new lab values in and incorporate past values]
OBJECTIVE
NAD Well today
[this entire section should be plain text, no bullets. One idea per line]
[Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
ASSESSMENT
(this entire section should be plain text, no bullets. One idea per line)
(For this whole section, please build on existing chart for context, if available)
[Issue, problem or request 1 (issue, request, topic or condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Assessment, likely diagnosis for Issue 1 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Differential diagnosis for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Investigations planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Treatment planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Relevant referrals for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Issue, problem or request 2 (issue, request, topic or condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Assessment, likely diagnosis for Issue 2 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Differential diagnosis for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Investigations planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Treatment planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Relevant referrals for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Issue, problem or request 3, 4, 5 etc (issue, request, topic or condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Differential diagnosis for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Investigations planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Treatment planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[Relevant referrals for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(Never come up with your own 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.)
PL
[this entire section should be plain text, no bullets. One idea per line]
[list any past medical conditions and conditions treated in clinic that are not presenting as current issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PLAN
Informed consent obtained
[this entire section should be plain text, no bullets. One idea per line] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[list the plan for today’s visit. plain text no bullets. One item per line] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
FUTURE PLAN
[this entire section should be plain text, no bullets. One idea per line]
[list plans for the next few visits as well as things to consider for the future, including lab testing. Plain text, no bullets. One item per line] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
ACTION ITEMS
[this entire section should be plain text, no bullets. One idea per line]
[list items that I have told patient I would do after our visit such as order labs, set aside supplements, send in prescriptions, get referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PATIENT ACTION PLAN
[this entire section should be plain text, no bullets. One idea per line]
Dear [patient name],
It was wonderful to check in with you. Below is a summary of what we discussed in today’s visit.
Thank you for trusting me with your care.
Warmly,
Dr. Amy Rolfsen
NUTRITION
[this entire section should be plain text, no bullets. One idea per line]
[list any dietary, lifestyle, hydration suggestions discussed during the visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
SUPPLEMENTS
[this entire section should be plain text, no bullets. One idea per line]
[list supplements recommended. Both new and existing supplements, including doses. Please organize this by time of day that the supplements shoudl be administered, as well as duration of treatment. If there is more than one step to the program, please list this as Step 1, Step 2, Step 3, Step 4] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
MEDICATIONS
[this entire section should be plain text, no bullets. One idea per line]
[list medications recommended, both new and existing. Include dosing, timing and duration of treatment as well as refill status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
LAB TESTING
[this entire section should be plain text, no bullets. One idea per line]
[list laboratory testing recommended] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
REFERRAL
[this entire section should be plain text, no bullets. One idea per line]
[list any referrals discussed during this visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
NEXT APPOINTMENT
[Please mention when the next recommended visit is and either a duration of 25 minutes or 50 minutes. If there are no instructions, please default to 4 weeks from appointment date and a 25 minute follow up appointment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
(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 that it’s not mentioned; just leave the relevant placeholder or omit the section entirely.)
