EMIS Template

Problem: [insert SNOMED compliant diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Do not invent or infer a diagnosis.) History: [describe current issues, reasons for visit, discussion topics, history of presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [describe past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [mention medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [mention allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Social: [describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Examination: [describe physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [document vital signs including HR, BP, RR, SpO2, temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Comment: [Imp] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [plan of action including planned investigations, referrals and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)