CARDIO CONSULT OCC (Copy)

Struktura szablonu

To jest struktura, której Notat używa podczas pisania notatki z wizyty — nigdy nie wypełniasz jej ręcznie.

[Insert patient’s name, age, sex, very brief patient history with presenting complaint and cardiac issues that are being addressed or followed]
[Focus on the cardiac issues]
[Do not give a significant list of medical issues in this section]
[Make it very brief with a maximum of 1 sentence total]
[He/she] was previously followed by [Insert name of previous Cardiologist]. (If not previously followed, do not include this phrase)
[He/she] was seen in consultation on [Insert date of appointment]

Cardiac Past Medical History:
(hyphenated list)
- [Condition]
[if there is no history of heart disease, simply state "No history of heart disease".]
(if history of cardiac surgery, include name of surgeon)
(include hypertension, dyslipidemia, and diabetes in this section, if present)
(do NOT list any MILD valvular disorders)

Other Past Medical History:
(hyphenated list)
- [Condition]

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- [marital status, number of children, number of grandchildren if applicable] 
- Occupation: [job title]

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

History of Present Illness:
(in paragraphs)
[Describe chronology of cardiac symptoms and associated features]
[Summarize important aspects of the review of symptoms last]
[Do not list investigation results]
[Do not include social history]
[Do not include smoking status/history]
[Do not include alcohol status/history]
[Do not include family history]

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #)]
- [Stated physical examination findings, one line per system. If a normal exam is mentioned, use standard phrasing (eg., Respiratory: Chest clear to auscultation bilaterally, no wheezes or crackles; Cardiac: Normal S1/S2, no murmurs, rubs or gallops)]

ECG
[Brief summary of ONLY the ECG described during the patient visit. Do not fabricate.]

Investigations:
(Hyphenated list)
(Separate into different types of tests)
(List in reverse chronological order within each test subtype)
[e.g., Echocardiogram pending/results]
[Echocardiogram findings should be concise and focus on the formal "Echo Impression", listing in order: LV function, only important chamber size/findings, only important valvular findings, only other important findings]
[Stress test findings should be concise and focus on overall "Impression", listing whether or not the test was positive or negative for ischemia by ECG and/or clinical criteria]
[Do not include: Minimal echocardiographic findings e.g., trivial or mild valvular regurgitation, mitral annular calcification unless SEVERE, left atrial size unless SEVERE]

Important parameters:
(hyphenated list)
(for each parameter, list the values in reverse chronological order)
(if the parameter is not available, do not list the parameter)
(for dates, only put month and year)
- [calculated BMI, dates]
- [weight, dates]
- [Hgb, dates]
- [MCV, dates]
- [Platelets, dates]
- [creatinine, dates]
- [eGFR, dates]
- [potassium, dates]
- [HbA1c, dates]
- [Triglyceride, dates]
- [LDL, dates]
- [Lipoprotein a, dates]
- [Apolipoprotein B, dates]
- [Non-HDL cholesterol, dates]
- [NT-proBNP, dates]
- [TSH, dates]
- [free T4, dates]
- [Urine ACR, dates]

Impression and Plan:
(Use medical terminology if appropriate. Do not fabricate.)
(Do not use words like Initiate or Arrange - keep the plan points brief)
(The last item should always be Follow Up Plan)
(Format in prose. Write it like I am writing it to the referring doctor.)
[In this section, include a few sentences summarizing the clinician's diagnostic reasoning and decision-making as discussed during the encounter. Explicitly outline 1. the clinician's clinical assessment of the symptom, e.g., chest pain including estimated level of risk as stated during the visit; 2. whether current investigations are sufficient or if further testing is required, and the rationale; and 3. the planned management strategy, including decisions to reassure, discharge, or continue therapy. Use the clinician's explanations and nuanced reasoning from the conversation, not generic phrasing.]
[point form clear plan that was made, highlighting medication changes and clear testing plan prior to the next visit, including follow up plan]
[Always refer to the Family MD or primary care practitioner as PCP]
[Never use the word "educate" in this section]
[When asking a family MD or primary care practitioner to follow up on something or giving instructions, ask in a polite professional way]

Thank you for involving me in the care of your patient. Please do not hesitate to contact me with any questions or concerns.

The patient consented to the use of a medical AI scribe to support documentation. Please excuse any errors.