face to face “F2F” seen with wife, Susan.
Type 2 diabetes, duration 10 years.
HbA1c 65 mmol/mol, previous result 72 mmol/mol. Medications: Metformin 1000mg twice daily, Gliclazide 80mg twice daily.
Non-HDL 3.5 mmol/L, QRisk 10%, taking Atorvastatin 20mg daily, compliant.
Urine ACR 2.0 mg/mmol, on Ramipril.
BP 130/80 mmHg.
Patient reports feeling well with their diabetes, no significant issues.
Self-recorded sugar levels: fasting levels between 6-8 mmol/L, post-meal levels between 8-10 mmol/L.
No hypos reported.
Insulin: Novorapid 6 units before meals, Lantus 20 units at bedtime.
CGM: Time in range 70%, time above range 25%, time below range 5%. Noted overnight lows.
Medication compliance: Excellent.
Patient goals: To maintain HbA1c below 58 mmol/mol.
Plan:
1. Continue current medications.
2. Review HbA1c in 3 months.
3. Reinforce healthy eating and exercise advice.
4. Next diabetes review due in 6 months.
History:
- Presented with a cough for 2 weeks.
- ICE: Patient is concerned about the cough and wants to rule out any serious cause.
- Presence or absence of red flag symptoms relevant to the presenting complaint: No red flag symptoms.
- Relevant risk factors: Smoker, 20 cigarettes per day.
- PMH: / PSH: - Type 2 diabetes, hypertension.
- DH: Drug history/medications: Metformin, Gliclazide, Atorvastatin, Ramipril. Allergies: NKDA.
- FH: Relevant family history: Father with heart disease.
- SH: Social history: Smoker, lives with wife.
Examination:
- Chaperone offered and present.
- Vital signs listed: BP 130/80 mmHg, HR 78 bpm, RR 16 breaths/min, Sats 98% on room air, Temp 37.0°C.
- Physical or mental state examination findings: Chest clear to auscultation.
- Investigations with results: Chest X-ray ordered.
Impression:
Cough. Assessment: Acute bronchitis.
- Differential diagnosis for Issue: Pneumonia.
Plan:
- Investigations planned for Issue: Chest X-ray.
- Treatment planned for Issue: Advised rest, fluids, and paracetamol for symptomatic relief.
- Relevant referrals for Issue: Advised to return if symptoms worsen or if any red flag symptoms develop.
[face to face “F2F” OR if calling via telephone “T/C”] [specify whether anyone else is present I.e. “seen with…” (based on introductions).
Specify type 1 or 2 diabetes, or MODY. Specify duration of diabetes
HbA1c result, compare to old result. Specify what diabetes medications they are taking currently only. Do not include medications I am starting today (all on one line)
Non-HDL result only (not LDL or total cholesterol). Specify QRisk, whether they are taking any cholesterol lowering medications at present and if compliant (all on one line)
Urine ACR result. Specify whether on SGLT-2 or ACE-i/ARB at present (all on one line)
BP. Leave blank if no BP taken
How are they doing with their diabetes? [Do not include any management plans here, this is solely to gauge how patient is doing with their diabetes management]
Include any self-recorded sugar levels, specifying range of levels and what time of day they are taken in relation to meals. Do not specify each BM value but a range of values over a certain period of time
Specify if any hypos - how low, how they were treated and if there were any obvious triggers. Do they have hypo awareness? Do not include if hypos not asked/mentioned
Specify which insulin is taken and when, and how many units of each insulin
If a CGM is used, specify time in range, time above range, time below range and very high levels. Make note of any particular trends e.g. low sugars overnight, high sugars after meals etc. Do not include if not on a CGM or not mentioned
Include medication compliance if mentioned
Add any patient goals
Formulate plan, including when next diabetes review is due. Each action should be numbered
For any non-diabetes related issues, transcribe separately using the following template
History:
- [History of presenting complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [ICE: Patient's Ideas, Concerns and Expectations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Presence or absence of red flag symptoms relevant to the presenting complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Relevant risk factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [PMH: / PSH: - include the past medical history or surgical history (if applicable)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [DH: Drug history/medications (if mentioned)]. [Allergies: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [FH: Relevant family history (if applicable)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [SH: Social history I.e. lives with, occupation, smoking/alcohol/drugs, recent travel, carers/package of care (if applicable)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Examination:
- [include if chaperone offered or if they are present]
- [Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable)] (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] (only include if applicable, and use as many bullet points as needed to capture the examination findings) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Investigations with results (include only if applicable and if mentioned)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Impression:
[Issue, problem or request (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue (condition name only) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Differential diagnosis for Issue (include only if applicable and if mentioned)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [Investigations planned for Issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Treatment planned for Issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Relevant referrals for Issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Repeat all above steps for subsequent issues, separating each issue with a new paragraph]
(Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc - use only the transcript, contextual notes or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)
