(Do not write paragraphs)
(Do not say "x year-old gender". Instead shorten in to: "x yo M/F/X")
(Must only have one sentence per line)
(Only include sections **if relevant**)
(Must omit if no information is provided)
(Do not include headings; present notes as a natural, structured narrative)
(Must maintain detailed points in dot form (but do not include bullets))
(Must include negative findings if discussed)
(Must provide rationale for decisions if mentioned)
(Exclude brackets, quotation marks, bullets, and repeated statements)
(Must include Age and Gender if mentioned)
(Do not include personal identifiers, phone numbers, or MyMedicare comments)
(Must use Australian spellings)
(Do not start any sentence with "Patient")
(Do not start any sentence with the patient's name)
(Must exclude any section **if all subfields are empty or marked "Not discussed"**)
(Must not generate blank headings)
(Only include **relevant** details that were actually mentioned)
(Do not include placeholders like "Not discussed" or "Not applicable")
(Must place a gap between sections such as history, examination, impression and plan)
(Include "seen with" - if this is a child who was seen with their mother or father)
(You must treat any info in the context box as past history)
(Conditional logic for consult type: {If single-issue consult → use single issue format. If multiple issues → separate clearly into sections}
(If there are multiple unrelated issues discussed during the consult - separate them with separate placeholders)
[1. Issue, problem or request 1 (include issue, request or condition name only)]
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1 (include only if applicable)]
- [Past medical history, previous surgeries, medications, relevant to issue 1 (include only if applicable)]
[2. Issue, problem or request 2 (include issue, request or condition name only)]
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2 (include only if applicable)]
- [Past medical history, previous surgeries, medications, relevant to issue 2 (include only if applicable)]
[3. Issue, problem or request 3, 4, 5 etc (include issue, request or condition name only)]
- [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc (include only if applicable)]
- [Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc (include only if applicable)]
Past history: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Possible medication side effects if explicitly mentioned]
Family history: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Relevant past family history and social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Examination: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable)]
- [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)
(Do not include a comment saying "Not performed during this consultation")
- [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc (include only if applicable)]
- [Findings from the physical examination, including vital signs and any abnormalities]
- [Negative findings mentioned on examination]
- [Only put examination findings in once] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
- [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable)]
(MSE: Add a Mental State Examination (MSE) if consult relates to mental health using all voice characteristics and deep understanding of the context)
(Investigations (ONLY IF DISCUSSED))
SECTION "Impression"
(Working diagnosis)
(Differential diagnoses: auto_suggest based on history + examination)
SECTION “Plan”
Lifestyle & education: (auto_suggest based on diagnosis)
Medications: (If discussed)
Further investigations: (If discussed)
Referrals: (If discussed)
Follow-up: (If discussed)
Safety netting: (auto_include based on risk factors)