Generic Consult

OVERALL_INSTRUCTIONS

Chief Complaint

Assessment of [symptoms]

Template

Dear Dr. , Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of [symptoms]. The patient was seen [in person or via telemedicine]. We spoke in [English or Mandarin]. [They were seen alone/accompanied by]. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that Empathia saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. History of presenting illness: [Brief description of when the patient's symptoms, when they were initially discovered, and initial testing done] Past medical history: [medical_history] (List numerically with each having its own line) Medications: [drug_name] (List numerically with each having its own line) Allergies: [allergies] (List numerically with each having its own line) Social history: Exercise: [exercise] Meals: [meals] Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] Family history: [family_history] [Family history of breast cancer, VTE, or other malignancies] Exam: Weight: Height: Blood pressure: Heart rate: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Investigations: [investigations] (Organize lab values by date and list each lab value on its own line) Impression and Plan: [name] is a [age] year old [gender] with [symptoms and diagnosis]. Follow-up: I have arranged for follow-up in [time] Patient Counseling: Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Dr. Leo Hu, MD, FRCPC Elida Medical Centre