Surgeon's note (custom)

Patient Details: [Date of admission] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Date of discharge] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Age in years] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Gender or sex] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [BHT number] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Presenting Complaint: [Reason(s) for consultation, including specific surgical concerns or symptoms related to previous surgery] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [History of presenting complaint including duration, severity, aggravating/alleviating factors, associated symptoms, nature, previous treatments and responses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Medical and Surgical History: [Relevant past medical and surgical history, including hospitalisations and outcomes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Current medications including anticoagulants, pain medications, antibiotics] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Social history including smoking, alcohol use, and occupation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Allergies: [Known allergies including drug, latex or material allergies relevant to surgical care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Examination: [Vital signs including BP, HR, Temp, O2 sats etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Physical examination findings, focusing on areas relevant to surgical assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [System-specific examination (e.g. abdominal, cardiovascular, respiratory) relevant to the surgical issue] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Investigations: [Completed investigations relevant to surgical assessment including imaging and labs with results and dates] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Assessment: [Surgical issue or condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Diagnosis and clinical reasoning based on findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Differential diagnoses considered] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Investigations planned for diagnostic clarification or surgical planning] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Repeat this Assessment block for each additional issue as needed.) Operative Details and Management: [Surgical procedure planned including type, expected outcomes, potential risks] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Pre-operative preparation including fasting, medications, or lifestyle instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Post-operative care including hospital stay, analgesia, wound care, and follow-up plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Referrals: [Referrals to other services or specialties for multidisciplinary or follow-up care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Additional Notes: [Patient education and consent including discussion of procedure, risks, benefits and alternatives] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Emergency instructions for post-operative complications or red flags] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Concerns raised by patient or family and responses provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Condition at Discharge: [Haemodynamic parameters at discharge and any post-operative complications relevant to surgery] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Discharge Plan: [Discharge instructions, medications, wound care, follow-up appointments and return precautions] (Only include if explicitly mentioned in transcript or context, 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.)