Basic Pre Charting Template

This template can be imported directly into your DeepCura account.

Below you’ll find both the prompt and an example of its generated output.

If you’re new to the Template Library, learn how to import templates here.

  • PATIENT INFORMATION
    Name:
    Date of Birth:
    Date of service:
    
    CHIEF COMPLAINT
    chief_complaint
    Summarize the patient's primary reason for seeking medical care in a concise sentence. Quote the patient's own words when necessary.
    chief_complaint
    
    HPI
    hpi
    Write a detailed, chronological narrative of the history of present illness. Include the onset, duration, location, quality, severity, timing, context, modifying factors, and associated signs/symptoms. Use medical terminology and include pertinent positives and negatives from the transcript.
    hpi
    
    REVIEW OF SYSTEMS
    ros
    Provide a brief review of systems, covering all relevant organ systems. Focus on pertinent positives and negatives related to the chief complaint, using information from the transcript. Use medical terminology and a consistent format for each system.
    ros
    
    PAST MEDICAL HISTORY
    past_medical_history
    List the patient's significant past medical conditions, surgeries, and hospitalizations. Use a consistent format and medical terminology, pulling information from the transcript.
    past_medical_history
    
    FAMILY HISTORY
    family_history
    List the patient’s family history pulling information from the transcript. If not mentioned in the transcript, omit this section.
    family_history
    
    SOCIAL HISTORY
    social_history
    List the patient’s relevant social history including any smoking, alcohol use, drug use, employment, and living situation, pulling information from the transcript. If not mentioned in the transcript, omit this section.
    social_history
    
    MEDICATIONS
    medications
    List the patient's current medications, including dose, route, and frequency. If not mentioned in the transcript, omit this section.
    medications
    
    ALLERGIES
    allergies
    List any drug allergies or intolerances, including the reaction. If none, state "No known drug allergies." If not mentioned in the transcript, omit this section.
    allergies