paedrv

[date of review written in YYMMDD format] [Patient's Name] cc: [General Practitioner's Name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Problem List: 1. [List of medical issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include DSM-5TR or ICD-10 code where appropriate.) Medications: 1. [List of medication and dose – instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Ceased Medications: - [List of medication – reason for stopping] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Support Team: - [List of involved supports] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include name of therapist, company/provider, and frequency of sessions.) Parents: - [List parents' first names] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Comment on separated parenting if noted.) School: [School Name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Grade: [School Year] [YYYY] Teacher: [Teacher's name(s)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) I had the pleasure of reviewing [patient's first name] who is now [age in years and months] on the [Date of Review]. They attended with [name of parent] who is their [mother/father]. The appointment was in clinic rooms. School Progress: [Summary of patient's school progress and challenges] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Use the patient's and parents' names to attribute statements. Include comments on stimulant medication efficacy, behavioural challenges, learning supports, and suspensions if applicable.) Home Progress: [Summary of patient's home life and any relevant issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Include any aggression, anxiety, ability to complete homework, parental stress, exposure to domestic violence, or adverse childhood experiences. Attribute statements to the patient and/or caregiver.) Allied Therapies and External Supports: [Details of allied health involvement] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format. Include therapist names, provider, frequency, and therapy goals. Do not summarise as a list.) Mental Health: [Assessment of patient's mood and mental health] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Avoid repeating details from earlier sections. Attribute statements.) Sleep: [Assessment of patient's sleep patterns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Attribute statements. Do not summarise allied therapist involvement.) Diet: [Assessment of patient's dietary habits and weight trajectory] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Attribute statements. Do not summarise allied therapist involvement.) Toileting: [Assessment of patient's toileting habits and any current issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences and paragraph format. Attribute statements. Include symptoms of constipation, presence of night wetting, and laxative use—name, dose, frequency, and adherence.) Side Effects of Medications: [Report on any side effects experienced by the patient] (Only include if explicitly mentioned in transcript or context, else state "Nil side effects of significance reported today." Write in full sentences and paragraph format. Attribute statements. Do not report medication side effects elsewhere in the letter.) Examination: Weight – [Weight in kg] (Only include if explicitly mentioned in transcript or context, else omit.) Height – [Height in cm] (Only include if explicitly mentioned in transcript or context, else omit.) BMI – [BMI in kg/m2] (Only include if explicitly mentioned in transcript or context, else omit.) BP – [BP in mmHg] (Only include if explicitly mentioned in transcript or context, else omit.) [Summary of physical examination findings] (Only include if explicitly mentioned in transcript or context, else omit. Write in paragraph format. If HSDNM CC is written, this denotes "Heart sounds dual with no murmur, chest clear.") Summary: [Summary of concerns from today's consult for patient] (Only include if explicitly mentioned in transcript or context, else omit. Write in paragraph format.) Plan: - [Outline of treatment plan including medication adjustments, referrals, therapy, investigations, follow-up] (Only include if explicitly mentioned in transcript or context, else omit. Use as many bullet points as needed.) (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 include 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.)