Primary Care Consultation Template

(Never invent or assume patient details, assessments, plans, interventions, or any clinical information. Use only the transcript, contextual notes, or clinical note as the source for all information. If information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, omit that placeholder entirely without stating that the information was not mentioned. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript. If symptoms and red flag information overlap, include the information in the red flags section only to avoid repetition.) [Whether verbal consent was obtained from the patient for the use of Heidi AI scribe and whether the option to opt out was offered] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence on a single line. If consent was gained, write: “Verbal consent for use of Heidi AI scribe and option for opt out.”) [Whether a chaperone was present or whether the patient declined a chaperone] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence on a single line.) Presenting Complaint: [The patient's current issues including reasons for visit, main symptoms, and duration] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.) History: [The history of the presenting complaint including onset, progression, and any relevant past medical history] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.) Symptoms: [The symptoms experienced by the patient including severity, frequency, and any associated factors] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.) Exclusion Of Red Flags: [All red flags that have been explicitly excluded based on the patient's history and symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each red flag as a separate paragraph.) Examination: [Findings from the physical examination including vital signs, general appearance, and any specific system examinations performed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. List objective data observations first, followed by other examination findings. Write in full sentences, with each finding as a separate paragraph.) Social: [Relevant social history including lifestyle factors, occupation, living situation, and support systems] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.) Plan: [The management plan including investigations ordered, treatments prescribed, follow-up arrangements, and patient education] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each plan item as a separate paragraph.)