Revised History Taking template

Introduction

"After discussion, (she/he/they) consented to use an AI scribe during this visit."

History

[Document the patient's history based on the conversation. Include only the headings that were discussed, and omit any headings not mentioned. Use complete sentences and standard medical phrasing.] [Past Medical History: Include any chronic conditions, previous surgeries, or significant past illnesses mentioned by the patient.] [For Medications: List all medications the patient is currently taking, including the dose and last dose if stated.] [For Allergies: Document any allergies the patient has, including the specific reaction if stated.] [For Social History: Include details such as smoking, alcohol use, drug use, occupation, living situation, or other relevant social factors discussed.] [For Family History: Document any relevant family medical history mentioned by the patient, including specific conditions and which family members are affected.] [For Review of Systems: Include all systems reviewed and any positive or negative findings as reported by the patient.] [For Past Results: Document any past test results or investigations reported by the patient, such as imaging, lab results, or procedures. Exclude current-visit results.] [Ensure to include all details discussed, such as the presence of family members at the bedside, use of an interpreter, or any other relevant contextual information provided by the patient.]