Scribe BC - UPCC Cerner Note

"Scribe BC - UPCC Cerner Note ""The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks."" **Reason for visit:** [Patient's current issues including reasons for visit, discussion topics, history of presenting complaints, and associated symptoms. Detail the duration, progression, and any self-treatment efforts.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Preface with appropriate pronoun if known, otherwise preface with ""Patient"". Write in bullet form without bullet symbol. Start a newline for each bullet item. In this section take the transcript and place it in an organized manner including chronological when possible. Start chronologically with what the patient was doing at the onset. Always order history so that it is in the order of chronologic not in the order of how the patient reports it during the transcript. If the history is over several days, then preface the list item with Date: e.g. 7/21 - symptom began while doing activity or spontaneous onset.) **Systems:** [Include any denials of symptoms related to other body systems, and descriptions of normal bodily functions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in bullet form without bullet symbol.) **Past Medical History** *[list past medical diagnoses, chronic conditions, and dates of diagnosis if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) *[list past surgical procedures and their approximate dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Social History** * [describe occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) * [describe social relationships and living situation, including family members and their locations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) * [detail habits including smoking status, alcohol consumption, and physical activity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Family History** * [describe family medical history, including cause and date of death for deceased family members, and any inherited conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Medications** * [list current medications, including dosage and frequency, that require refill] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Allergies** * [list any known drug allergies or other allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Immunizations** * [list all vaccines discussed, including tetanus, covid, flu, pneumonia, childhood vaccines] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) --- Objective ""Do not insert default values such as 'No abnormalities detected' for any system not explicitly documented. Omit the heading and section entirely for any system not explicitly documented."" **Vitals**: [record vital signs including blood pressure, pulse, and weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **HEENT**: [describe findings related to head, eyes, ears, nose, and throat, including neck mobility, carotid bruits, intraoral lesions, and cataracts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Cardiovascular**: [describe cardiovascular findings, including heart sounds, murmurs, and JVP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Respiratory**: [describe respiratory findings, including lung auscultation and air entry] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Abdomen**: [describe abdominal findings, including tenderness, distention, bowel sounds, and bruits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Genitourinary**: [describe genitourinary findings, including hernias, testicles, skin fold conditions, and lymphadenopathy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.) **Extremities/Skin**: [describe skin lesions, including location, characteristics, and distribution] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) [describe any fungal infections of the skin or nails, specifying location and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) [describe nail changes and specific conditions affecting the nails] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) [describe pulse quality and palpability in the lower extremities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Neurological:** [describe neurological findings, including mental status, cranial nerves, coordination, muscle power, reflexes, pronator drift, Romberg test, Dix-Hallpike test, and sensation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) ** Investigations**: [list recent lab results including specific values for hemoglobin, electrolytes, GFR, and glucose, along with the date of testing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) [describe recent urinalysis findings, including the presence of proteinuria, glucosuria, ketonuria, and bacteriuria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) [note any investigations that are not on file or are overdue, such as A1C or lipid panel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol. When I mention a preliminary xray report, note that ""We are awaiting formal radiology report."") --- **Assessment and Diagnosis** [summarize current issues including reasons for visit] ( Write in paragraphs of full sentences.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) [number all active diagnoses and conditions, and for each one, provide indented bullet points with relevant clinical information, such as severity, chronicity, contributing factors, impact on function, stability, and control status] (Use a numbered list for each diagnosis, followed by hyphenated sub-points beneath each item. Only include this section if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely.) **Differential Diagnosis** [list 5-10 possible causes for this specific patient's presentation. Always include the ones that were discussed. Always include a few additional suggestions. Always include serious and life threatening causes. Always include a couple of mitigating notes for the relevant serious ones e.g. ""Myocardial infarction, but no chest discomfort""] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Make it very organized in a hyphenated list.) **Plan** **Investigations**: [list any ordered blood tests or other investigations, specifying what parameters are to be checked] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Prescriptions**: * [describe any new topical treatments prescribed, specifying the condition they are for] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) * [describe any refills of current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Referral**: [detail any referrals made, including the specialty or clinic and the purpose of the referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) **Counselling & Follow-up**: * [describe any counselling or advice given to the patient, including recommended follow-up examinations and their frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) * [document any specific educational points discussed with the patient regarding their conditions and treatment, including potential interactions or side effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) * [note any relevant administrative or social information, such as the patient's primary care provider status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list without bullet symbol.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)"