General Medicine template
General Medicine notes, written while you talk
A general clinic sees everything in one morning: blood pressure reviews, coughs, diabetes, back pain. The General Medicine template keeps each note consistent, with vital signs, a review of systems and long-term conditions in their own sections.
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Built for a General Medicine clinic
The consultations this template is laid out for, among others:
- Hypertension reviews
- Type 2 diabetes
- Fever and cough
- Headache
- Back pain
- Medicine refills
See a General Medicine note
A short consultation in Urdu, and the note Hikayat Scribe writes from it.
The consultation (Urdu)
Doctor: Kya masla hai?
Patient: Do hafte se sar dard hai, subah zyada hota hai.
Doctor: BP ki dawai le rahe hain?
Patient: Haan, amlodipine 5. Kabhi kabhi bhool jata hoon.
Doctor: BP abhi 150 over 95 hai. Namak kam karein, dawai roz lein, do hafte baad dobara check karwayein.
The note
- Presenting complaint
- Headache x2/52, worse in the mornings.
- Drug history
- Amlodipine 5 mg OD; reports occasional missed doses.
- Vital signs
- BP 150/95.
- Long-term conditions
- Hypertension, suboptimally controlled; partial adherence.
- Patient education
- Advised to reduce salt intake and take antihypertensive daily.
- Follow-up
- BP recheck in 2 weeks.
Fictional patient. Sections that were not discussed are left off.
What the General Medicine template records
Alongside the usual history and examination, every General Medicine note has these sections:
Only what was discussed
Vital signs are recorded only when they are said out loud. The scribe never estimates a reading or completes a set. Any section that was not covered is simply left off the note, so it never fills up with "not discussed".
Set it once
Choose General Medicine when you start a clinic or ward note, or tick "Always start my notes with this specialty" and it stays selected until you change it. Specialty templates are part of Pro and Enterprise, and included in the 7-day free trial.
The rest of the note
- Ranked differentials with the reasoning shown, for you to choose from
- Investigations and medicines you tick yourself; nothing is prescribed until you do
- ICD-10 and SNOMED codes for your review
- Your name, qualifications, registration number and the date and time on the printed note
How it works
- Record. Press the button and talk with your patient in any of nine languages, or dictate on your own.
- Review. The note is ready in seconds. Tick the diagnosis, investigations and medicines you are keeping, and edit anything.
- Use it. Copy, print or email the note, with your name, qualifications and registration number on it.
Common questions
- Does it handle a quick refill visit as well as a long consultation?
- Yes. A two-minute refill produces a short note; a long consultation produces a full one. Sections that were not covered are left off either way.
- Can I record blood pressure readings by saying them?
- Yes. Say the reading out loud and it goes into Vital signs. The scribe never estimates a reading you did not say.
- Can I use the General Medicine template for ward notes?
- Yes. Specialty templates work for outpatient clinic notes and inpatient ward notes.
- What if I also have my own template?
- Both are used together: your own sections first, then the specialty sections.
Related
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