Which instructions are used for the default templates?

Instruction: “If provided, include the patient's complaints, symptoms, medical history, and current medications.”

Instruction: “If provided, include the patient's vital signs, physical exam findings, and any diagnostic tests.”

Instruction: “If provided, include the patient's diagnosis. Pull up research on this assessment and elaborate on it.”

Instruction: “If provided, include the patient's treatment plan and recommendations based on this plan. Go into detail about the treatment plan and recommendations.”

Instruction: “Document the main complaint in the patient’s own words by recording the primary issue that led them to seek medical attention. Use direct quotes whenever possible to accurately capture the patient's perspective. For example, ‘swelling of tongue and difficulty breathing and swallowing.’ Ensure specificity by clearly noting the symptoms that are most distressing or urgent to the patient.”

Instruction: “Provide a detailed narrative of the current illness, starting with a brief description of the patient, including age, gender, and relevant medical history (e.g., 77-year-old woman with CAD, DM2, asthma, and HTN). Describe the onset and progression of symptoms, including when they began and any factors the patient believes may have triggered them. Document associated symptoms and those explicitly denied by the patient (e.g., denies SOB, chest pain, itching, nausea, and rashes). Include any treatments received (e.g., IV Benadryl, Solumedrol, Pepcid) and their effectiveness. Highlight recent lifestyle changes or exposures, such as travel, allergens, new medications, or dietary changes. Summarize how the illness impacts daily functioning, including eating, drinking, and taking medications.”

Instruction: “List all past surgeries with relevant dates, including the year and type of surgery, such as ‘status post vaginal wall operation for prolapse in 2006’ or ‘status post cardiac stent in 1999.’ Note any relevant complications or residual effects, particularly if a past surgery affects the current condition or ongoing care.”

Instruction: “Include a comprehensive list of the patient’s diagnosed medical conditions, such as CAD, hyperlipidemia, HTN, DM2, asthma, and GERD. Summarize key diagnostic data related to each condition, including past imaging results or lab values (e.g., transthoracic echocardiogram showing LVEF 60-65%). Highlight important disease management milestones, such as the most recent HbA1c level for diabetes.”

Instruction: “Describe the patient’s living situation and support system, including details about where they live, with whom, and their level of independence in daily activities. For example, ‘The patient lives with her daughter and manages all activities of daily living independently.’ Document lifestyle factors, noting the patient’s use of tobacco, alcohol, or illicit drugs, as well as significant social factors that might impact their health. Additionally, if the patient’s past or current occupation is relevant to their condition, include that information here.”

Instruction: “Document the health history of the patient's immediate family members, including information about parents, siblings, and children, while noting any significant conditions such as cardiac disease or cancer. Highlight any patterns or hereditary conditions that may influence the patient's health, such as a strong family history of cardiac disease.”

Instruction: “List all known allergies and reactions, including both drug and non-drug allergies, and specify the type of reaction (e.g., ‘Sulfa drugs - rash’). Highlight any allergies that are relevant to the current treatment plan, paying special attention to those that could influence the management of the presenting condition, such as allergies to medications commonly used in treatment.”

Instruction: “List all current medications, including the name, dosage, frequency, and purpose of each medication the patient is taking. For example, ‘Ramipril (Altace) 10 mg BID – ACE inhibitor for hypertension and diabetes.’ Note any relevant side effects or interactions, particularly medications that could contribute to the current illness, such as ACE inhibitors in cases of angioedema. Additionally, identify any omitted medications by documenting if the patient has not taken any medications on the day of the visit.”

Instruction: “Conduct a systematic review of each organ system, including the patient’s reported symptoms or the absence of symptoms for each system, even if they are unrelated to the chief complaint. Highlight both positive and pertinent negative findings by documenting symptoms that are present as well as those that are explicitly denied, for example, ‘Pulmonary - hard to get a breath in but not short of breath.’ Keep the information concise and relevant, focusing on symptoms pertinent to the current presentation and any underlying conditions that may be affected.”

Instruction: “Record vital signs accurately, including all measurements such as temperature, pulse, blood pressure, respiratory rate, and oxygen saturation. Document findings for each body system examined, noting specific observations; for example, ‘ENT - large swollen tongue and cheek on the left side, with the tongue obscuring the view of the posterior oropharynx.’ Highlight any abnormal findings, emphasizing physical exam results that deviate from the normal range, particularly those related to the chief complaint. Ensure completeness by checking that all relevant systems are examined, especially those directly related to the presenting symptoms.”

Instruction: “Include all relevant lab results and imaging by documenting key diagnostic tests conducted, such as electrolyte levels, complete blood count, and EKG findings. Highlight any abnormal results and their significance by focusing on findings that fall outside the normal range and discussing their implications in relation to the patient’s condition.”

Instruction: “Provide a concise summary of the patient’s condition, starting with a brief statement that summarizes the patient’s main issues and possible diagnoses. Discuss differential diagnoses by listing the potential causes of the presenting problem and providing reasoning for the most likely diagnosis based on the available data. Outline the plan for each identified issue, including specific actions such as medication adjustments, further diagnostic testing, or specialist consultations, for example, ‘ENT consult to rule out abscess or foreign object.’ Address any necessary precautions or adjustments, noting changes in medication due to allergies, interactions, or the patient’s current condition, such as ‘HOLD Altace, which is likely the cause of angioedema.’ Finally, ensure clear communication of the next steps by providing detailed instructions on follow-up care, including when to resume medications, how to manage symptoms, and when the next evaluation will occur.”

Instruction: “If provided, include the patient's complaints, symptoms, medical history, and current medications.”

Instruction: “Brief medical history or background relevant to the current visit.”

Instruction: “Detailed observations made during the current visit.”

Instruction: “Plan for patient care or recommendations moving forward.”