Hirad Nursing Ax

**Presenting Problem:**[describe patient's age, gender, and duration of presenting problem, including any recent relevant medical events] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Onset:** [describe the onset of the presenting problem, including any relevant details about when and how it started] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Symptoms:** [list the symptoms the patient is experiencing related to the presenting problem] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.) **Current Rx:** [list the current treatments or medications the patient is receiving] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.) **Relevant Medical Hx:** [describe any relevant past medical history that is pertinent to the presenting problem] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Red flags / Allergies:** [list any red flags or allergies that are relevant to the patient's condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.) **Assessment** **Airway:**[describe the status of the patient's airway] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Breathing:** [describe the patient's breathing status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Circulation: **[describe the patient's circulation status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Disability: **[describe the patient's pain level and Glasgow Coma Scale (GCS) score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Exposure / Environment:** [describe any relevant details about the patient's exposure or environment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Fluids:** [describe the patient's fluid status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Glucose:** [describe the patient's glucose level] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **Social:** [describe any relevant social factors that may impact the patient's condition or treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Interventions:** [describe any interventions that have been performed or are planned, including further assessments by medical officers] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief statements.) **PLAN: ** [document plan including follow-up and other referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points.) (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.)