Custom note templates

Use bold subsection labels. Use - item bullets and blank lines between content blocks.
If an entire section has no supported content, use Not Provided. Omit unsupported subsections and optional details.
Clearly identify prior results and distinguish them from current findings.

###### Objective

**Physical Exam Findings**

- Abdomen: Mild epigastric tenderness today.

**Imaging Results**

- Prior abdominal ultrasound from last month: No gallstones.

###### Allergies

Not Provided

Purpose and sources
Summarize patient-reported symptoms and explicit symptom denials from the transcript, grouped by organ system.

Include
Reported symptoms, explicit negatives, and qualifications such as occasional or possible.

Exclude and placement
Physical examination findings belong in Objective. Diagnoses, clinical reasoning, and management decisions belong in Assessment and Plan.

Organization and format
Use one bullet per discussed system: - **System:** Findings.
Group related symptoms together and document each finding once under its best-fitting system.
Use clinical terminology when the meaning is clear; otherwise retain the patient's wording.

Examples
Illustrative only; do not copy clinical facts.
Input: Patient reports occasional cough and denies shortness of breath. Clinician states the lungs are clear and orders a chest X-ray.
Expected output:
- **Respiratory:** Reports occasional cough; denies shortness of breath.

- **Respiratory:** Reports occasional cough; denies shortness of breath.

### Heading hierarchy:
ALL section headings must use exactly six hash marks (######).
Within any section body, sub-elements that need visual labels (problem titles in Assessment & Plan, subsection labels in Objective, etc.) must use **bold text** (`**Label**`), not heading-level markdown.
Every heading must be followed by a blank line (double newline) before body content.
### Missing information:
If an entire section has no supported content, use `Not Provided`. Omit unsupported subsections and optional details.
---
### Current vs Prior Information:
The focus of every note is the current encounter. When prior encounter information is referenced, explicitly indicate it using language such as "Previously…", "At last visit…", "Per prior records…". Do not blend prior and current encounter data without this explicit tagging.

Use supplied facts only. Do not infer absent facts or copy clinical facts from illustrative examples.

**Purpose and sources**
Capture the major topic(s) of the encounter — the primary reason(s) the patient is presenting today. This section functions like the title of the note, giving the reader an immediate sense of what the encounter covers.
- Use the stated reason(s) for the encounter, whether expressed by the patient or clinician, including follow-up or preventive visits.
**Exclude and placement**
- Do NOT include plans, assessment details, or detailed clinician discussion.
**Organization and format**
- Keep entries brief — a short phrase or symptom label.
- Use `- item` bullets, one per stated reason for the encounter.
**Examples**
Illustrative only; do not copy clinical facts.
Input: Patient: “I'm here for my blood pressure follow-up, and my right knee has been hurting.” Clinician: “We'll order a knee X-ray.”
Output:
```text
- Blood pressure follow-up
- Right knee pain
```

**Purpose and sources**
Document a concise, clinically focused history of the present illness based on what the patient reported.
- Include only what the patient reports.
**Include**
- Chronology: Use specific timeframes when stated.
- OLDCARTS GUIDE: Use Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity as a guide to cover all relevant HPI details.
- **MEDICATIONS FROM PRIOR ENCOUNTERS**: Pull through medication names and doses from prior encounter context only if those medications are discussed in the current encounter transcript. If a medication was stopped during the current encounter, note that where relevant.
**Exclude and placement**
- Do not include clinician observations, clinician questions, assessments, clinical reasoning, recommendations, or plans.
- No treatment plans, future actions, or recommendations. These belong in Assessment & Plan.
- Do not include vitals: Do not include weight, BMI, or vitals in the HPI.
- **PROPOSED ≠ CONFIRMED**: Treatments about to start (e.g., "She has elected to begin…") reflect current encounter decisions, not past history — exclude from HPI.
- Conversational, incidental, administrative, and repeated details.
**Organization and format**
Group history by complaint using a bold label followed by concise bullets. Include pertinent reported details without repeating them in an introductory paragraph. Separate complaint blocks with blank lines.
Summarize rather than quote the transcript verbatim.
**Examples**
Illustrative only; do not copy clinical facts.
Input: Patient: “My right knee started aching three days ago after jogging. It's 6 out of 10, worse on stairs, and better with rest. I've also had a dry cough for a week, without fever.” Clinician: “The knee is tender on examination. I'll order an X-ray.”
Output:
```text
**Right knee pain**

- Aching pain began three days ago after jogging.
- Severity 6/10; worse with stairs and improved with rest.

**Cough**

- Dry cough for one week.
- Denies fever.
```

**Purpose and sources**
Document the patient's pertinent medical, surgical, family, and social history.
- Use relevant information from the transcript and supplied clinical context for all four history groups.
**Include**
- **Medical History:** Established prior or ongoing conditions pertinent to today's care.
- **Surgical History:** The patient's procedures, including the year and surgeon's name when available.
- **Family History:** Pertinent conditions in relatives. Identify the relative and condition when available; do not document every family member's full medical history.
- **Social History:**
	- Living situation: household, housing type, and stability.
	- Occupation, including relevant exposures.
	- Substance use: tobacco, alcohol, and recreational drugs; include reported quantities or pack-years when available.
	- Relationships and support system.
	- Sexual history when relevant to the visit.
	- Diet and exercise.
**Organization and format**
Use bold labels for Medical History, Surgical History, Family History, and Social History. Separate groups with blank lines and use `- item` bullets within each group.
- Medical: one condition per bullet.
- Surgical: `[Procedure]: [Year if stated], [Surgeon if stated]`.
- Family: `[Relative]: [Condition]`.
- Social: group related details under bold labels such as Home, Employment, Substances, Relationships, Sexual History, and Diet and Exercise.
Keep entries concise and factual.
**Missing information**
- Omit history groups with no supported information.
- Omit unavailable optional details, such as a procedure's year or surgeon.
- Omit social history domains without supported information. Include Sexual History only when relevant.
- If the entire section has no supported content, use `Not Provided`.
**Examples**
Illustrative only; do not copy clinical facts.
Input: During a hypertension follow-up, supplied prior records list hypertension and an appendectomy in 2012. Patient: “My mother also has hypertension. I live with my partner, work as a teacher, and have never smoked. I have a headache today.” No surgeon, diet, exercise, or sexual history is provided.
Output:
```text
**Medical History**

- Hypertension, per prior records.

**Surgical History**

- Appendectomy: 2012, per prior records.

**Family History**

- Mother: Hypertension.

**Social History**

- **Home:** Lives with partner.
- **Employment:** Teacher.
- **Substances:** Never smoked.
```

**Purpose and sources**
Summarize patient-reported symptoms and explicit symptom denials, grouped by organ system.
**Include**
- Reported symptoms, explicit negatives, and relevant qualifications such as “occasional” or “possible.”
**Exclude and placement**
- Physical examination findings belong in Objective.
- Diagnoses, clinical reasoning, and management decisions belong in Assessment and Plan.
**Organization and format**
- Use one bullet per discussed system: `- **System:** Findings.`
- Group related symptoms together and document each finding once under its best-fitting system.
- Use clinical terminology when the meaning is clear; otherwise retain the patient’s wording.
**Missing information**
- Omit systems without supported information.
- If the entire section has no supported content, use `Not Provided`.
**Example**
Illustrative only; do not copy the clinical facts.
Input: Patient reports occasional cough and denies shortness of breath.
Output:
- **Respiratory:** Reports occasional cough; denies shortness of breath.

**Purpose and sources**
Document the patient's allergies as provided in the transcript.
**Include**
- Capture the allergen name AND the reaction if available.
- Include all allergies mentioned (medications, environmental, food, etc.).
**Organization and format**
- Use `- item` bullet format if multiple allergies.
- Format each entry as: `[Allergen]: [Reaction if stated]`.
**Missing information**
If allergy information was not discussed in the transcript, use `Not Provided`.
**Examples**
Illustrative only; do not copy clinical facts.
Input: Patient: “Penicillin gives me hives. I'm also allergic to shellfish, but I don't remember the reaction.”
Output:
```text
- Penicillin: Hives.
- Shellfish
```

**Purpose and sources**
Document physical examination findings, measurements, and completed diagnostic results stated or reviewed during the encounter.
**Include**
- **Physical Exam Findings:** Document all relevant physical examination findings as observed and stated by the clinician.
- **Laboratory Data:** Document completed laboratory results provided in the transcript. Be specific: if named labs are mentioned, list them by name and value. Include reference ranges or clinical interpretation only if stated by the clinician.
- **Imaging Results:** Document completed imaging results provided in the transcript. Include modality, body region, and findings as stated.
- **Other Diagnostic Data:** Document any other diagnostic data (e.g., ECG, spirometry, biopsy, scoring tools) as provided in the transcript.
**Exclude and placement**
- Place patient-reported symptoms in HPI or ROS, and assessments and management decisions in Assessment and Plan.
- Include only provider-observed signs, not patient-reported symptoms. For other diagnostic data, apply the same symptom vs. sign distinction: only objective/provider-generated data here.
- Do not list ordered or pending tests here; place those only in Assessment and Plan. Do not list ordered or pending imaging here; place it only in Assessment and Plan.
CRITICAL: Distinguish carefully between symptoms (subjective — patient's experience, belongs in HPI) and signs (objective — provider-observed findings, belongs here). Example: Patient stating "stomach pain" is a symptom (HPI). "Abdominal tenderness to palpation" is a sign (Objective).
**Organization and format**
Organize this section using Physical Exam Findings, Laboratory Data, Imaging Results, and Other Diagnostic Data, each labeled in **bold text**. Use `- item` bullet format within each sub-section.
Structure physical examination findings appropriately for a clinical note (by system or body region if multiple systems examined).
**Missing information**
Omit any sub-section that has no transcript-supported data, with no heading or placeholder. If none of the four sub-sections have data, use `Not Provided` for the entire Objective section.
**Examples**
Illustrative only; do not copy clinical facts.
Input: Patient reports abdominal pain. Clinician: “There is mild epigastric tenderness on examination. Today's hemoglobin is 12.4 g/dL. We reviewed last month's abdominal ultrasound, which showed no gallstones. I'll order a CT of the abdomen.” No other diagnostic data is discussed.
Output:
```text
**Physical Exam Findings**

- Abdomen: Mild epigastric tenderness.

**Laboratory Data**

- Hemoglobin: 12.4 g/dL today.

**Imaging Results**

- Prior abdominal ultrasound from last month: No gallstones.
```

**Purpose and sources**
Document the clinician’s current assessment and management decisions. Use patient history, findings, and prior records only as discussed supporting context. Write directly from the clinician’s perspective.
**Include**
- Problems assessed, managed, or materially affecting today’s decisions, including existing diagnoses discussed today.
- Selected actions, contingencies, and counseling, alternatives, risks, benefits, side effects, or preferences that affected decisions or safe follow-through.
- Medication changes, including discontinuations. Prior medication details only when discussed today.
**Exclude and placement**
- Omit unaddressed conditions, conversational process, reassurance, and generic statements without specifics.
**Organization and format**
- Use consistent labels for problems shared with HPI. Put each action once under its best-fitting problem and category; do not repeat it in Plan.
Optional opening: 1–2 sentences only when they add information beyond the problem blocks.
Order problems by clinical importance. Combine related problems only when they share a plan, retaining each problem name.
Each block: **bold problem name**, optional plain-text assessment sentence (at most one), then `- **Label**: Content` bullets. Separate these elements and problem blocks with blank lines.
Use populated categories in this order:
- **Plan**: Other selected actions, contingencies, and decision-relevant counseling.
- **Tests**: Named laboratory, imaging, and other diagnostic tests ordered during the encounter; include body site and study details when supplied.
- **Medications**: Action and name; dose, frequency, route, and duration when supplied. Includes prescriptions, OTC medications, and supplements.
- **Lifestyle Measures**: Specific diet, exercise, or other measures discussed.
- **Referrals**: Specialty and stated instructions.
- **Follow Up**: Date or timeframe.
**Missing information**
Omit unavailable details, unsupported assessment sentences, and empty categories; no placeholder bullets. An assessment may stand alone. With no supported content, use `Not Provided` for the section.
**Examples**
Illustrative only; do not copy clinical facts.
Input: Clinician: “Hypertension remains above goal. I increased losartan to 50 mg orally daily, ordered a BMP, and set follow-up in four weeks.”
Output:
```text
**Hypertension**

Blood pressure remains above goal.

- **Tests**: BMP ordered.
- **Medications**: Increase losartan to 50 mg orally daily.
- **Follow Up**: Four weeks.
```
Input: Patient requests a higher dose. Clinician states hypothyroidism is controlled based on reviewed TSH; no medication decision or test order is stated.
Output:
```text
**Hypothyroidism**

Controlled based on the reviewed TSH result.
```

**Physical Exam Findings**

- Abdomen: Mild epigastric tenderness.

const patient = { name: "Example Patient", dateOfBirth: "1980-01-01" };

const patientDetails = [
  `Patient name: ${patient.name}`,
  `Patient DOB: ${patient.dateOfBirth}`,
].join("\n");

const template = {
  instructions: `Use supplied facts only.\n\n${patientDetails}`,
  sections: [
    {
      title: "History of Present Illness",
      instructions: "Summarize patient-reported symptoms and their chronology.",
    },
  ],
};