UPCC Cerner

Consent

The patient [or patient's first name, patient's mom, dad, daughter, son, family member if noted] 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

[OUTPUT STYLE: Generate a professional, structured clinical note suitable for EMR import, respecting the global formatting and omission rules.] [For each health issue discussed, provide detailed information including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. Use format as in the example below] [Write in bullet form without bullet symbol] (Have each concern as a numbered list format) (Avoid duplicating information) Example: 1. [Problem 1]: - [Detailed description and recent findings] - [Symptoms and onset] - [Relevant past medical history related to this problem] 2. [Problem 2]: - [Detailed description and recent findings] - [Symptoms and onset] - [Relevant past medical history related to this problem] [Any other relevant information that was discussed. Write in bullet form without bullet symbol.] (Avoid duplicating any information listed above) Systems: [Include any denials of symptoms related to other body systems, and descriptions of normal bodily functions.] (Only include if explicitly mentioned in transcript, context or clinical note, else 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 transcript, context or clinical note, else omit section entirely. Write in bullet form with a dash. Start a newline for each bullet item.) *[list past surgical procedures and their approximate dates] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. ) (Write in bullet form with a dash. Start a newline for each bullet item.) Social History * [describe occupation] (Only include if explicitly mentioned in transcript, context or clinical note, else 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 transcript, context or clinical note, else omit section entirely. Write as a single line.) * [detail habits including smoking status, alcohol consumption, and physical activity] (Only include if explicitly mentioned in transcript, context or clinical note, else 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 transcript, context or clinical note, else 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 transcript, context or clinical note, else 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 transcript, context or clinical note, else 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 transcript, context or clinical note, else omit section entirely. Write as a bulleted list without bullet symbol.)

On Examination

[Document physical examination findings organized by system or general observations. Include vital signs and relevant positive or negative findings. For example: VITAL SIGNS: - Blood pressure: [value] - Pulse: [value and rhythm] - Temperature: [value] General: - [General appearance and symptoms] Cardiovascular: - [Findings] Respiratory: - [Findings] Abdomen: - [Findings] Extremities: - [Findings] Other relevant systems as applicable] [If it's a televisit or audio visit, write "No examination is performed due to Televisit" for the Physical Exam Findings.]

Clinical Risk Score

[Omit this section entirely if N/A] [IF two or more required CENTOR fields are noted THEN] CENTOR SCORE FOR STREP PHARYNGITIS (Score each criterion as per standard Centor scoring; display only final score and risk level) Criteria: - [Criterion 1]: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Criterion 2]: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) TOTAL CENTOR SCORE: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RISK ASSESSMENT: [Low / Moderate / High] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [ENDIF] [Preferred clinical scoring algorithms are CENTOR, WELLS, PERC, CHADS2-VASc, HAS-BLED, NIHSS, GCS, SIRS, HEART, TIMI, ABCD2, OTTAWA ANKLE RULE, PHQ-9, GAD-7, PRAM] GLOBAL RULE: For every clinical scoring algorithm: [IF two or more required scoring fields are documented THEN] (Display the score name and context) (Display criteria and their values; if a criterion is not recorded, show "Not documented") (Display only the total score and risk category/interpretation) (Display in table format) [ENDIF]

Differential Diagnoses

In this section list 5-8 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" Make it very organized in a hyphenated list.

Diagnosis and Plan

[List each medical diagnosis or problem with a corresponding assessment and detailed management plan. Include differential diagnoses if applicable. Specify medications, dosages, follow-up plans, referrals, and any additional investigations required. Separate each problem and plan clearly. Use format as in the example below] IF a Clinical Risk Score is recorded above THEN list the score name and the associated risk. Do not report the score Total. For example: 1. [Diagnosis 1]: [Brief description of the condition and clinical presentation.] - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] 2. [Diagnosis 2]: [Brief description of the condition and clinical presentation.] - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] ... [n. Diagnosis n]: [Brief description of the condition and clinical presentation.] - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other]

Foot note

I have advised the patient to return, follow up with FP or to attend ER if condition is not improving or worsening. (If a lab test was requested add:) Test Results: [Patient first name] understands that [he/she] will receive a call only if test results are abnormal or alter the recommended management.