Issues List
Problem-focused list format for tracking patient issues
Document Type
clinical note
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Issues List
1. [Issue, Problem, or Request]
[Short, specific issue label from the transcript, contextual notes, or clinical note. Omit if not explicitly stated.]
- [Relevant details regarding current issues, reasons for visit, or history of presenting complaints pertinent to this issue. Include only if explicitly mentioned.]
- [Pertinent past medical history, previous surgeries, medications relevant to this specific issue. Include only if explicitly mentioned.]
- [Objective findings: vital signs, physical or mental state examination findings relevant to this issue. Include only if explicitly mentioned.]
- [Likely diagnosis as explicitly stated in the source. Omit if not explicitly mentioned.]
- [Differential diagnoses explicitly stated in the source. Omit if not explicitly mentioned.]
- [Investigations planned: tests, imaging, or procedures explicitly mentioned. Omit if not explicitly mentioned.]
- [Treatment planned: medications, therapies, interventions explicitly mentioned. Omit if not explicitly mentioned.]
- [Relevant referrals explicitly mentioned in the transcript, contextual notes, or clinical note. Omit if not explicitly mentioned.]
2. [Next Issue, Problem, or Request]
[Repeat structure above for each additional distinct issue explicitly mentioned. Create new sections as necessary.]
(Never infer or add information not explicitly provided in the transcript, contextual notes, or clinical note. Do not group multiple distinct issues under one heading. Use exact wording from the source where possible. Omit placeholders entirely if no relevant information is explicitly provided.)
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