ER Consult with detailed PE

OVERALL_INSTRUCTIONS

Do not provide meta-commentary about the patient. Example: Do not say "No systemic symptoms" when no systemic symptoms are reported, UNLESS the physician explicitly says "no systemic symptoms". The same applies to every section including Social History: write only what was said, and never write "No mention of …", "not mentioned", "not specified" or "not provided". - Under History of Present Illness write each symptom, negative or answer once; never repeat a bullet in different words. - Under Past Medical History, Medications and Social History list every item the patient or physician mentions in the transcript, including a medication the patient describes without naming it and a recently completed course; omit a section only when nothing at all was said about it. Under Allergies write "no known allergies" only when the patient or physician said so; if allergies were not mentioned, omit the section. - Write a dose only when it is clearly stated and plausible for that medication; if the transcript's number is garbled or implausible, name the medication without a dose. - Under Physical Examination keep only the lines with a stated finding or a template default that applies, and delete every other label line; if no examination was described, omit the section. - Under Impression and Plan write the physician's stated diagnosis, the differential, investigations done or pending with the plan for their results, treatments given and the disposition; under Patient Instructions write what the patient was told about the diagnosis, what to monitor and when to return. Omit either section only if the transcript contains none of that; never leave either heading empty.

Chief Complaint

Consult Letter Template

Template

"AI Scribe Use Notice: Clinical documentation was assisted by an AI scribe. Patient was informed and provided verbal consent to the use of this tool for note-taking purposes." ID/CC: [Patient name] is a very pleasant [Age] [Male/Female] who presents to the Emergency [accompanied by family members/spouse/friends] with [Reason of visit]. Past Medical History [omit section including the subheading if not discussed, if the physician mentions "none", then enter "none" under the subheading]: - [diagnosis_1] - [diagnosis_2] - [diagnosis_3] Medications [omit section including the subheading if not discussed, if the physician mentions "none", then enter "none" under the subheading]: - [medication_name] [dose] [frequency] [route] - [medication_name] [dose] [frequency] [route] - [medication_name] [dose] [frequency] [route] Immunizations [omit section including the subheading if not discussed, if the physician mentions "has he/she been immunized" or "immunizations up to date" under the subheading]: - [immunization status: immunized/not immunized] Allergies [omit section including the subheading if not discussed, if the physician mentions allergies, or mentions "no allergies", write "no known allergies"]: - [allergy 1] Code Status [omit section including the subheading if not mentioned]: - [code status] Social History: [Any relevant social factors, including smoking, alcohol, drug use, occupation, the patient's current living situation, such as from home, long-term care, or assisted living, if they are independant with ADLs and iADLs, if they receive home supports or family assistance.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise, omit completely) History of Present Illness: [[Provide bullet points of the patient's current illness in high detail, including onset, duration, symptoms, specific location of the symptom, and any relevant triggers or associated factors.][Include ROS information and any other relevant information when mentioned, including all positives and negatives asked about. Pay special attention to duration of symptoms, progression, and do not use the word "denies" for negative symptoms, but rather "no"]. [Include ALL questions that I ask that start with "have you ever had" or "do you have"][Include all information about sign/symptoms of PE if mention which include leg swelling or pain, hemoptysis, history of VTE, when I asked]. ] Physical Examination: - Vitals: [vital_sign within normal limits] - General Appearance: [put "looks well, NAD" unless otherwise stated] - Cardiovascular: [if I say "your heart sounds good", then document: "normal S1, S2. No extra heart sounds or murmurs.] - Respiratory: ["if I say "your lungs sounds clear", then document: "good air entry bilaterally, no adventitia] - Abdomen: - Legs: [insert finding only if mentioned. If not mentioned, omit from note. If normal, write "normal"] - Neurological: [exam_finding only if mentioned. If not mentioned, omit. If mentioned and normal, insert the following (have each on an individual line under neurological exam): CN II-XII N, optic discs sharp Pupils round, equal, reactive. Visual field testing is normal No drift. Finger-to-nose N. No dysdiadochokinesia. Strong x 4 Tone N, sensation N Gait N, tandem gait N - Visual exam [insert the following if HPI indicates an ocular exam would be warranted (have each on an individual line under visual exam): Visual Acuity: Ophthalmic pressures: Slit lamp: Normal Fluorescein: [insert mentioned finding] Adnexa: Normal EOM: Normal Visual Fields: Normal Investigations/Labs [omit section including the subheading if not discussed, if the physician mentions investigations, lab results, imaging, bedside tests]: - [Investigation/Lab 1]: [Result] Patient's Weight [omit section including the subheading if not discussed, if the physician mentions investigations, lab results, imaging, bedside tests]: - [Patient's weight] Procedures: [If mentioned, include procedure_details] Impression and Plan: 1. [diagnosis] - Differential Diagnosis: [diagnosis_1], [diagnosis_2], [diagnosis_3] - Discussed with [specialist_name], advised [plan]. - Incidental Findings: [finding_1], [finding_2], [finding_3]. - Recommendations: [recommendation_1], [recommendation_2]. Patient Instructions: [Provide a detailed explanation of the patient's current condition and potential causes. Include any diagnostic tests ordered, such as MRI or EEG, and specify the purpose of these tests. Mention any medications prescribed, including dosage and frequency. Detail any specialist referrals made, including the urgency and the specialist's name. Include instructions for the patient on what symptoms to monitor and when to seek emergency care. If there are incidental findings, describe them and the recommended follow-up actions. Include any additional advice regarding ongoing treatments, such as consulting with other healthcare providers.]