Advanced Care Directive:
2020. Reviewed with patient. No changes required.
Family History:
Mother is still living. Father passed away at age 82 due to a heart attack.
Social History:
Patient lives alone. She has two children and four grandchildren. She has a cat.
Home Living/Services:
Patient receives a home care package, level 3, provided by Aged Care Services. She receives assistance with cleaning and lawn mowing, once per week.
Recreation Activities:
Patient enjoys walking and knitting.
Alcohol and Tobacco Use:
Patient consumes approximately 5 standard drinks per week. Smoked 20 cigarettes per day from 1960 to 2000.
Immunisations:
Last COVID-19 vaccine dose received in March 2024. 2025 influenza vaccine recommended. Shingrix x2 received in 2023. Prevenar13 received in 2022. Whooping cough vaccine recommended every 10 years.
Medications:
Medications are up to date. No recent changes to medications. Takes a daily multivitamin.
Allergies:
No known allergies.
Mobility:
Patient’s mobility is good and she uses a walking stick. Balance is good. No falls in the past 12 months. Does not use a medical/falls alert buzzer.
Diet:
Patient eats 3 serves of fruit and 2 serves of vegetables per day. Eats takeaway or fast food once per month and dines out once per month. Drinks 8 glasses of water per day and 2 cups of tea per day. Breakfast is cereal with milk and fruit. Morning tea is a piece of fruit. Lunch is a sandwich. Dinner is chicken and vegetables.
Exercise:
Patient walks for 30 minutes, 3 times per week. Recommended at least 30 minutes of physical activity most days of the week.
Sleep:
Patient’s sleep is good. Sleeps for an average of 8 hours per night. Feels well rested most mornings. Does not nap during the day.
Bladder and Bowels:
No bladder or bowel problems. Patient is regular and continent.
Hearing:
Patient’s hearing is good. Does not use hearing aids. Last hearing check occurred in 2023.
Vision:
Patient wears glasses for reading. Optometrist is Dr. Smith, next review due in December 2024. Does not see an ophthalmologist.
Teeth:
Patient has natural teeth.
Activities of Daily Living (ADLs):
Patient is independent in all ADLs.
Driving:
Patient has an unrestricted driver’s license.
Skin Check:
Last skin check was in 2023, next due in 2025.
Advanced Care Directive:
[state what year patient's directive was completed] (Only include if explicitly mentioned in transcript. Write as a single sentence stating year. Include "Reviewed with patient. No changes required." only if explicitly stated.)
Family History:
[state whether mother and father are still living] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[if father passed away, mention how old he was and reason for death] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[if mother passed away, mention how old she was and reason for death] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention any relevant family medical history including siblings' health status] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Social History:
[state who the patient lives with or if they live alone] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention how many children and grandchildren the patient has] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if the patient has pets or great-grandchildren] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Home Living/Services:
[mention if the patient has a home care package, what level, and who is the provider] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if the patient is on a Commonwealth Home Support Program] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[describe duties the patient receives assistance with (e.g. cleaning, lawn mowing) and frequency] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if the patient is managing well at home] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention any home modifications such as ramps or handrails] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Recreation Activities:
[mention the patient’s recreational activities (e.g. walking, knitting, bingo)] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Alcohol and Tobacco Use:
[state how many standard drinks the patient consumes per week] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[if more than 10 drinks per week, include the recommendation: "Recommended no more than 10 standard drinks per week and at least 2 alcohol-free days."] (Only include if explicitly mentioned in transcript.)
[mention smoking status, including year started and stopped, and average cigarettes per day] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Immunisations:
[mention when the last COVID-19 vaccine dose was received or if patient does not wish further doses] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[state if patient received 2025 influenza vaccine] (Only include if explicitly mentioned in transcript. If not received, state it has been recommended.)
[state if patient received 2x Shingrix and in what year] (Only include if explicitly mentioned in transcript. If not received, state it has been recommended.)
[state if patient received Prevenar13 and in what year] (Only include if explicitly mentioned in transcript. If not received, state it has been recommended.)
[state if patient received whooping cough vaccine and in what year] (Only include if explicitly mentioned in transcript. If not received, state that it is recommended every 10 years.)
Medications:
[mention if medications are up to date] (Only include if explicitly mentioned in transcript. Write as "Up to date" if applicable.)
[state any recent changes to medications] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention supplements, vitamins or over-the-counter medications] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Allergies:
[list any allergies] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[if no allergies] (Only include if explicitly mentioned. State "No known allergies.")
Mobility:
[mention how good the patient’s mobility is and if they use aids (e.g. walking stick, wheelie walker)] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if patient’s balance is poor, fair or good] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if patient has had any falls in past 12 months] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if patient uses a medical/falls alert buzzer] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Diet:
[state how many serves of fruit and vegetables the patient eats per day] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention how often patient consumes takeaway or fast food and frequency of dining out] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention how many glasses of water per day] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention how many cups of tea or coffee per day] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[describe what the patient eats for breakfast] (Only include if explicitly mentioned in transcript.)
[describe what the patient eats for morning tea] (Only include if explicitly mentioned in transcript.)
[describe what the patient eats for lunch] (Only include if explicitly mentioned in transcript.)
[describe what the patient eats for dinner] (Only include if explicitly mentioned in transcript.)
Exercise:
[mention type, frequency, and duration of patient’s exercise activities] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[include recommendation: "Recommended at least 30 minutes of physical activity most days of the week."] (Only include if the patient is not physically active and recommendation is explicitly stated.)
Sleep:
[mention if patient’s sleep is good, fair, or poor] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[describe sleep pattern including average hours per night] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if the patient feels well rested most mornings] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[state if patient naps during the day and for how long] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Bladder and Bowels:
[mention any bladder or bowel problems] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[if male, describe any urinary flow issues] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention if patient is regular and continent] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Hearing:
[describe patient’s hearing, including impairment status] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention use of hearing aids and which side/bilateral] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[state when last hearing check occurred] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Vision:
[mention if patient wears glasses and for what purpose (reading, distance, both)] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[state optometrist’s name and next review date] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[state if the patient sees an ophthalmologist, who it is, and when next due] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Teeth:
[mention if patient has natural teeth or dentures] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[describe dentures: upper, lower, or full] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Activities of Daily Living (ADLs):
[state if the patient is independent in all ADLs] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[mention which activities require assistance] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Driving:
[mention if patient has an unrestricted driver’s license] (Only include if explicitly mentioned in transcript. Write in full sentences.)
[describe any driving restrictions] (Only include if explicitly mentioned in transcript. Write in full sentences.)
Skin Check:
[mention when the patient’s last skin check was and when next due] (Only include if explicitly mentioned in transcript. Write in full sentences.)
(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 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.)
