**Emergency Medicine Specialist - Routine Prescription Renewal**
**1. Consultation Details**
**Encounter:** Face-to-face consultation on 1 November 2024.
**Present:** The patient was present during the consultation.
**Reason for Visit:** The patient presented for routine medication renewal.
**Consent - AI Scribe:** Patient consent was documented for AI-assisted scribing.
**2. Clinical Review**
**Subjective Update:** The patient reports good adherence to their current medications, with no reported side effects or new health concerns.
**Objective Data:** No new objective data reviewed.
**Social Context:** The patient is travelling next month and requested a repeat prescription to cover their trip.
**3. Assessment & Plan**
**Assessment:** The patient's chronic conditions appear stable on current therapy. Clinical risk associated with re-prescribing is low. The request for repeat prescriptions for previously established and managed conditions is clinically appropriate.
**Medications Renewed:**
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Aspirin 75mg daily
**Safety Netting:** The patient was advised to seek immediate medical attention if they experience any chest pain, shortness of breath, or severe allergic reactions.
(STYLE: Concise and objective. FORMAT: Simple headings with bolding. TERMINOLOGY: Use standard medical terminology. OMISSION RULE: Omit any heading or sub-heading if not discussed.)
**1. Consultation Details**
**Encounter:** [type of consultation: face-to-face (F2F) or telehealth] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence format including date of service.)
**Present:** [who was present during consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.)
**Reason for Visit:** [reason for presentation, e.g., medication renewal] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.)
**Consent - AI Scribe:** [documented patient consent for AI-assisted scribing] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.)
**2. Clinical Review**
**Subjective Update:** [patient’s report on medication adherence, tolerability, any side effects, and whether any new health concerns were raised] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
**Objective Data:** [recent clinical data reviewed including dates and values, e.g., BP, HbA1c, pathology etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence. If no data reviewed, write: “No new objective data reviewed.”)
**Social Context:** [any relevant social, logistical, or contextual reason for medication renewal, e.g., travel, stockpiling] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in sentence format.)
**3. Assessment & Plan**
**Assessment:** The patient's chronic conditions appear stable on current therapy. Clinical risk associated with re-prescribing is low. The request for repeat prescriptions for previously established and managed conditions is clinically appropriate. (Only include if explicitly supported by transcript or context, else omit section entirely.)
**Medications Renewed:**
[list each medication re-prescribed including name and form if possible] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
- [Medication 1]
- [Medication 2]
- [Medication 3]
**Safety Netting:** [brief advice given regarding medication side effects and when to seek review] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.)
(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.)