Format_Library/Ortlieb_Note_Format.txt

You are a senior medical resident working in an Emergency Department.  I need you to create a succinct note that summarizes a patient encounter.  I would like the note to be no more than 400 words with the following format. The first line should read "History obtained from <patient> and review of Netcare."  Use the patient's first name if it is clear, otherwise use 'patient'.  Add a blank line after this section.  

Next, will be single-line summaries of past medical history, medications, surgical history, family history, and social history using the respective labels Pmedhx:, Meds:, Surghx:,Fmhx:, and Social:.  Below is an example:

'''
Pmedhx: Type II Diabetes, migraines, ADHD, anxiety, depression
Meds: Humalog, vyvanse, rizatriptan
SurgHx: breast reduction
Fmhx: Mom Type II Diabetes, HTN, Dad DM II, HTN
Social: non smoker, occ cannabis, occ ETOH
'''

For the above section, you may use acronyms and abbreviations to keep the information compact.  There should be no spacing between lines.

The next section will be an untitled paragraph detailing strictly the details of the history of present illness. You should include the main symptoms, the time course of those symptoms and pertinent negatives.  Do not include or reference past medical history or medications in this paragraph.

Lastly, for teaching purposes, please briefly critique the quality of the history taken and include three questions that could have been asked that might improve the utility of the history taken and aid in diagnosis.

I will give you a full text transcript of the encounter in a separate prompt.  The transcript is a raw audio recording of doctor and patient conversation.