Comprehensive Medical Chart Notes

Patient Demographics: - Patient Name: [Enter Patient Name] (only include if explicitly mentioned in the consultation or medical records) - Date of Birth: [Enter Date of Birth] (only include if explicitly mentioned in the consultation or medical records) - Gender: [Enter Gender] (only include if explicitly mentioned in the consultation or medical records) - Contact Information: [Enter Contact Information] (only include if explicitly mentioned in the consultation or medical records) - Emergency Contact Information: [Enter Emergency Contact Information] (only include if explicitly mentioned in the consultation or medical records) - Primary Care Provider: [Enter Primary Care Provider] (only include if explicitly mentioned in the consultation or medical records) - Insurance Information: [Enter Insurance Information] (only include if explicitly mentioned in the consultation or medical records) Vital Signs: - Blood Pressure: [Enter Blood Pressure] (only include if explicitly measured during the consultation) - Heart Rate: [Enter Heart Rate] (only include if explicitly measured during the consultation) - Respiratory Rate: [Enter Respiratory Rate] (only include if explicitly measured during the consultation) - Temperature: [Enter Temperature] (only include if explicitly measured during the consultation) - Oxygen Saturation: [Enter Oxygen Saturation] (only include if explicitly measured during the consultation) - Weight: [Enter Weight] (only include if explicitly measured during the consultation) - Height: [Enter Height] (only include if explicitly measured during the consultation) - BMI: [Enter BMI] (only include if explicitly calculated during the consultation) - Pain Level: [Enter Pain Level] (only include if explicitly assessed during the consultation) Medical History: - Chronic Conditions: [Enter Chronic Conditions] (only include if mentioned in the consultation, describe in detail, and provide relevant dates or timelines) - Previous Surgeries: [Enter Previous Surgeries] (only include if mentioned in the consultation, list each surgery along with dates and outcomes) - Family History of Diseases: [Enter Family History of Diseases] (only include if explicitly mentioned, list relevant family conditions) - Social History: [Enter Social History] (only include if explicitly mentioned in the consultation, such as smoking, alcohol use, drug use, etc.) - Psychiatric History: [Enter Psychiatric History] (only include if explicitly mentioned in the consultation) Immunization Records: - Vaccines Administered: [Enter Vaccines Administered] (only include if explicitly mentioned in the consultation, list each vaccine and its date of administration) - Vaccines Due: [Enter Vaccines Due] (only include if explicitly mentioned in the consultation, list any upcoming vaccinations and their dates) Medications: - Current Medications: [Enter Current Medications] (list each medication including dose, frequency, and duration) - Past Medications: [Enter Past Medications] (only include if explicitly mentioned in the consultation, list medications and reasons for stopping them) - Herbal Supplements: [Enter Herbal Supplements] (only include if explicitly mentioned in the consultation, list each supplement and dose) Allergies: - Drug Allergies: [Enter Drug Allergies] (only include if explicitly mentioned in the consultation, list each allergy and type of reaction) - Food Allergies: [Enter Food Allergies] (only include if explicitly mentioned in the consultation, list each allergy and type of reaction) - Environmental Allergies: [Enter Environmental Allergies] (only include if explicitly mentioned in the consultation, list each allergy and type of reaction) Diagnosis: - Primary Diagnosis: [Enter Primary Diagnosis] (only include if explicitly mentioned in the consultation, provide diagnosis name and relevant clinical details) - Secondary Diagnoses: [Enter Secondary Diagnoses] (only include if explicitly mentioned, list each diagnosis with relevant clinical details) - ICD-10 Codes: [Enter ICD-10 Codes] (only include if explicitly mentioned, list corresponding codes for each diagnosis) Laboratory Results: - Blood Work Results: [Enter Blood Work Results] (only include if explicitly mentioned in the consultation, list each test and its result) - Imaging Results: [Enter Imaging Results] (only include if explicitly mentioned in the consultation, list each imaging study and its result) - Other Diagnostic Results: [Enter Other Diagnostic Results] (only include if explicitly mentioned in the consultation, list any other diagnostic tests and their results) Treatment Plan: - Medications Prescribed: [Enter Medications Prescribed] (only include if explicitly prescribed during the consultation, list each medication including dose, frequency, and duration) - Referrals: [Enter Referrals] (only include if explicitly mentioned in the consultation, list any referrals made to specialists or other healthcare providers) - Further Investigations: [Enter Further Investigations] (only include if explicitly ordered during the consultation, list any tests or investigations) - Lifestyle Modifications: [Enter Lifestyle Modifications] (only include if explicitly discussed during the consultation, such as dietary changes, exercise plans, etc.) - Follow-up Appointments: [Enter Follow-up Appointments] (only include if explicitly scheduled during the consultation, provide follow-up details) Patient Education: - Information Provided: [Enter Information Provided] (only include if explicitly discussed in the consultation, list any educational materials provided to the patient) - Counseling Given: [Enter Counseling Given] (only include if explicitly discussed in the consultation, describe counseling on topics like health conditions, lifestyle, etc.) - Follow-up Instructions: [Enter Follow-up Instructions] (only include if explicitly mentioned in the consultation, provide detailed follow-up instructions) (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 include 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.)