F2F: Patient presented today with a three-day history of a sore throat, cough, and mild fever. She reports feeling generally unwell and has noted some body aches. She denies any difficulty breathing or chest pain. No significant past medical history. She reports no known allergies.
Examination: Temperature 38.2°C. Mildly erythematous pharynx. No tonsillar exudates. Lungs clear to auscultation.
Diagnosis or impression: Upper respiratory tract infection (URTI), likely viral.
Plan: Advised rest, fluids, and paracetamol for symptomatic relief. Encouraged to monitor for worsening symptoms, such as difficulty breathing or chest pain, and to seek further medical attention if these develop. Provided safety netting advice regarding potential complications. Follow-up not required unless symptoms worsen or do not improve within a week. Patient was given a leaflet on self-care for URTI. Date: 1 November 2024
[face to face “F2F” OR if calling via telephone “T/C”]. (only include state if it is a face to face or telephone consultation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
History: [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Examination: [describe physical examination findings] (only include describe physical examination findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Diagnosis or impression: [state diagnosis or clinical impression] (only include state diagnosis or clinical impression if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan: [describe management plan, treatment options, follow-up instructions, and safety netting advice] (only include describe management plan, treatment options, follow-up instructions, and safety netting advice if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 information from the transcript.)
AI - Please make the note take up less room by not using bullet points
AI - Please make the note take up less space by removing the space between paragraphs
AI - Please remove the word History from the template and start the note F2F: or T/C: then insert the history.