PC: [Chief Complaint(s)] (Include chief complaint(s) on the same line with "PC:". If multiple chief complaints, then add a full stop after each of them. If single chief complaint, do not include full stop. Do not include any details of the chief complaint in this section as all details are to be included in HPC. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
HPC: [Start with "Patient presented on" then date of presentation to hospital". Then provide a detailed account of the history of the presenting complaint, including onset, progression, associated symptoms, and any relevant factors. Conduct a systematic review of each body system, noting any positive or negative findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Negatives to be included on a separate line, starting with "Denied any", without being separated as their own section.)
PMH:
[document any past medical conditions, hospital admissions, and surgeries] (This should be a list with bullet points. If patient has specifically type 2 diabetes, add next to it (on insulin) if there is an insulin present on their drug history. If patient has a background of atrial fibrillation or atrial flutter and they are on anticoagulant, add next to it in brackets a not with the anticoagulant in the format shown on the following example "Atrial Flutter (on apixaban)". If a patient has a past medical history of any cancer, then if further information about it, such as previous treatment and current management approach, was obtained during the consultation, include it using the format demonstrated on the following examples - "Breast cancer with widespread metastasis to liver and bones - On best supportive care", "Prostate cancer - Under surveillance", "Myeloma - On active treatment with chemotherapy". Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
DH:
[list all current medications, including dosages and over-the-counter supplements] (This should be a list with bullet points. Do not abbreviate gram or grams. Abbreviate micrograms to "mcg". Abbreviate milligrams to "mg". Abbreviate any non-instant release formulation, such as "MR" and "XL". Frequency should be recorded with abbreviations, such as OD, BD, TDS, QDS. If medication taken once daily at night, then use ON. Include exact time of administration if included in history in a 24h format. If a medication is taken "as required" include after frequency, abbreviate to "PRN". Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies / ADRs: [list any allergy or adverse drug reactions. If patient has allergy or adverse drug reaction to an antibiotic, include when the reaction happened, detailed information of the reaction signs and symptoms, and whether or not there was need for medical therapy to manage the reaction.] (This should be a list with bullet points. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Starting with "FH:" mention any relevant family medical history, including hereditary conditions and illnesses] (This should be a list with bullet points. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. If no family history has been mentioned during the consultation, then do not include this section at all.)
SH:
[describe the patient's social circumstances, including occupation, living situation, smoking, alcohol consumption, and recreational drug use] (This should be a list with bullet points. If the patient is an active smoker, then follow the following format "Smoker - #/day - # pack years". If the patient is an ex-smoker, then follow the following format "Ex-smoker - Stopped # years ago - # pack years". If the patient is an ex-smoker but they stopped smoking over 10 years ago AND they have less than 1 pack-year history, then record as "Non-smoker". Alcohol history should be recorded as "No alcohol consumption" if the patient denied any alcohol consumption, or "No significant alcohol consumption" if the patient denied frequent alcohol consumption or has a consumption of under 6 units per week. If alcohol consumption per week is over 6 units, then detailed alcohol history should be noted including units per week. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
O/E:
[document findings from the physical examination, including general appearance, and detailed examination of relevant systems] (Always abbreviate "soft and non-tender" to "SNT", "Heart sounds" to "HS", and "Abdomen" to "Abdo". Formal of heart sounds should be noted as demonstrated on the following example "HS I + II +" 0 if no murmur noted, or information of the murmur if present. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
NEWS [Include the NEWS score of the patient as a number] - [Vital signs in the following format: "BP #/#mmHg; HR #bpm; Sats #% on (if on oxygen then #L if on room air then RA); (If temperature is under 37.1C then "Apyrexial", otherwise record as Temp ##.#C)"; ACVPU (Document this only with the observation, such as "Alert", "Confused", "Responsive to Voice", "Responsive to Pain", "Unresponsive")
Investigations
[Bloods: CRP #; Hb #; WCC #; Neut #; Plt #; INR #; PT #; APTT # (next line)
Urea #; Na #; K #; Creat 67 (baseline #); eGFR # (baseline #); cCa #; Phos #; Mg # (next line)
Any other blood tests available following the format above] (There should be no symbols between test and result unless symbol is part of the result such as negative based excess. Test should be separated by the symbol ";" if they are on the same line. If a test is dynamic, such as Troponins, it should be on its own line showing first the initial measurement then an arrow right symbol then the next measurement as demonstrated on the following example "Troponins 50 -> 100". If a blood gas analysis is present, this should be included on a separate line abbreviated to "VBG", "ABG", or "CBG" depending on type. If ABG, then include in brackets the amount of supplementary oxygen in form of FiO2 and delivery method if present, otherwise note in brackets "on room air". Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[list any investigations that have been performed, including blood tests, ECG, imaging, and other diagnostic procedures, along with their results] (Do not include separate sections for these investigations as they are all under the investigations section. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Impression:
[provide a summary of the clinical impression or differential diagnosis based on the history, examination, and investigations] (This should be a list with bullet points. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan:
[outline the management plan, including any further investigations, treatments, referrals, and follow-up arrangements] (This should be a list with bullet points. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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.)
