Clinical Documentation Prompt Library

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section. Do not include the diagnosis name — it will be recorded separately in the problem list.

Separate each problem block with a single blank line. Do not add any header, label, or number before each block.

For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation.

[Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled.]
        - [Plan bullet: brief action, adjustment, or follow-up item]
        - [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Do not include the diagnosis name anywhere in the output
2. Do not add any header, label, or number before each problem block
3. Assessment: one unlabeled telegraphic prose statement
   - For chronic/ongoing problems: include trend language and current medication/dose
   - For acute/new problems: include key findings and clinical interpretation; omit trend language and medication status
4. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
5. Use a hyphen (-) for all bullets
6. Indent all bullets with 8 spaces
7. Keep bullets concise (ideally under 10 words per bullet)
8. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
9. Add a blank line between each problem block
10. Add a blank line between the last problem block and any boilerplate text
11. Add a blank line between each boilerplate statement
12. Add a blank line before the follow-up line
13. Only include the follow-up statement once, at the end
14. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Stable on Flovent 44mcg 2 puffs BID with spacer; albuterol use minimal.
        - Continue Flovent 44mcg 2 puffs BID
        - Continue albuterol PRN
        - Reassess control at next visit

Follow-Up: Return to clinic in 3 months or as needed.

---

Worsening; persistent symptoms despite Flovent 44mcg 2 puffs BID and albuterol PRN.
        - Step up to Flovent 110mcg 2 puffs BID
        - Continue albuterol PRN
        - Return sooner if symptoms not improving

Follow-Up: Return to clinic in 6 weeks or as needed.

---

Improved on Vyvanse 20mg PO daily per parent and teacher report; no side effects.
        - Continue Vyvanse 20mg PO daily
        - Reassess at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

---

Inadequate symptom control on Concerta 27mg PO daily per parent and teacher report.
        - Transition to Vyvanse 20mg PO daily
        - Reassess response at one-month follow-up

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Stable; BMI unchanged since last visit, currently on dietary counseling and activity plan.
        - Continue dietary counseling
        - Encourage 60 min physical activity daily
        - Recheck BMI at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

---

Stable on Flovent 44mcg 2 puffs BID; albuterol use minimal.
        - Continue current regimen

Mild rhinorrhea, no fever; consistent with viral URI.
        - Supportive care, fluids
        - Tylenol/Motrin PRN

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

Stable on Vyvanse 30mg PO daily; parent reports good focus and behavior at school.
        - Continue Vyvanse 30mg PO daily

Right TM bulging and erythematous; consistent with bacterial AOM.
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d
        - Tylenol/Motrin for pain control

PCMH Reminder

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

Improved on Flovent 110mcg 2 puffs BID; symptoms well controlled, albuterol use rare.
        - Step down to Flovent 44mcg 2 puffs BID
        - Continue albuterol PRN
        - Reassess control at next visit

Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain.
        - RICE protocol
        - Ibuprofen 400mg PO q6h PRN
        - Weight bearing as tolerated

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic in 3 months or as needed.

For each problem discussed, write one concise telegraphic assessment statement that captures the key clinical findings, interpretation, and rationale for the management decisions made. Do not include the diagnosis name — it is already recorded in the problem list. Do not include medications, dosages, orders, labs, imaging, or referrals — these are already entered as discrete orders in the chart and will display automatically beneath the assessment.

Focus each statement on the clinical reasoning: what was found, why the chosen course of action is appropriate, and any important clinical context (e.g., trend language for chronic problems, severity, risk factors, relevant negatives on exam). Include forward-directed thinking such as return precautions or contingency triggers where naturally applicable.

Separate each assessment statement with a single blank line. Do not add any header, label, or number before each statement.

[Assessment statement: clinical findings, interpretation, and rationale. No diagnosis name. No medications, orders, or plan items. Unlabeled.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all assessment statements and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Do not include the diagnosis name anywhere in the output
2. Do not include medications, dosages, lab orders, imaging orders, or referrals — these are discrete chart entries that display automatically
3. Do not add any header, label, or number before each statement
4. Write each assessment as one or two telegraphic prose sentences
5. For chronic/ongoing problems: include trend language (improved, stable, worsening) and note current therapy status (e.g., "on current regimen" or "despite current therapy") without listing specific medications or doses
6. For acute/new problems: include key exam findings, clinical interpretation, and reasoning
7. Use standard medical abbreviations (PRN, BID, PO, etc.) when they appear naturally
8. Add a blank line between each assessment statement
9. Add a blank line between the last statement and any boilerplate text
10. Only include the follow-up statement once, at the end
11. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Persistent symptoms despite current controller therapy consistent with inadequately controlled asthma; stepping up treatment given ongoing rescue inhaler use multiple times per week.

Follow-Up: Return to clinic in 3 months or as needed.

---

Healthy 4yo with normal growth, development, and exam; no acute concerns. Anticipatory guidance reviewed and parent questions addressed.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

Acute vomiting with tolerating small sips, moist mucous membranes, and non-distended non-tender abdomen consistent with mild dehydration without need for IV fluids at this time; oral rehydration appropriate, return to ED if unable to maintain hydration.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

Inadequate symptom control on current stimulant per parent and teacher report; transitioning to alternative medication to assess response.

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Rhinorrhea and cough without fever or red flags consistent with uncomplicated viral URI; supportive care appropriate, family declined COVID testing.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Mild rhinorrhea without fever consistent with viral URI; supportive care appropriate.

Right tympanic membrane bulging and erythematous consistent with bacterial AOM; antibiotic therapy initiated given exam findings.

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Left lateral ankle tenderness without instability consistent with mild lateral ankle sprain; conservative management with RICE protocol appropriate, return if not improving in one week.

Sore throat with rapid strep negative and throat culture pending; cannot exclude strep pharyngitis at this time, will contact family if culture positive.

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic as needed and pending strep culture results.

---

Stable on current controller therapy with minimal rescue inhaler use; continue current regimen.

Mild rhinorrhea without fever consistent with viral URI; supportive care appropriate.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

Improved on current stimulant per parent and teacher report; no side effects, good focus and behavior at school. Continue current regimen.

Right tympanic membrane bulging and erythematous consistent with bacterial AOM; antibiotic therapy initiated.

PCMH Reminder

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section.

For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation.

[Problem/Diagnosis Name]
[Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled.]
        - [Plan bullet: brief action, adjustment, or follow-up item]
        - [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Write the problem/diagnosis name on its own line
2. Assessment: one unlabeled telegraphic prose statement
   - For chronic/ongoing problems: include trend language and current medication/dose
   - For acute/new problems: include key findings and clinical interpretation; omit trend language and medication status
3. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Keep bullets concise (ideally under 10 words per bullet)
7. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
8. Add a blank line between each problem block
9. Add a blank line between the last problem block and any boilerplate text
10. Add a blank line between each boilerplate statement
11. Add a blank line before the follow-up line
12. Only include the follow-up statement once, at the end
13. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma
Stable on Flovent 44mcg 2 puffs BID with spacer; albuterol use minimal.
        - Continue Flovent 44mcg 2 puffs BID
        - Continue albuterol PRN
        - Reassess control at next visit

Follow-Up: Return to clinic in 3 months or as needed.

---

Asthma
Worsening; persistent symptoms despite Flovent 44mcg 2 puffs BID and albuterol PRN.
        - Step up to Flovent 110mcg 2 puffs BID
        - Continue albuterol PRN
        - Return sooner if symptoms not improving

Follow-Up: Return to clinic in 6 weeks or as needed.

---

ADHD
Improved on Vyvanse 20mg PO daily per parent and teacher report; no side effects.
        - Continue Vyvanse 20mg PO daily
        - Reassess at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

---

ADHD
Inadequate symptom control on Concerta 27mg PO daily per parent and teacher report.
        - Transition to Vyvanse 20mg PO daily
        - Reassess response at one-month follow-up

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Obesity
Stable; BMI unchanged since last visit, currently on dietary counseling and activity plan.
        - Continue dietary counseling
        - Encourage 60 min physical activity daily
        - Recheck BMI at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

---

Asthma
Stable on Flovent 44mcg 2 puffs BID; albuterol use minimal.
        - Continue current regimen

Viral URI
Mild rhinorrhea, no fever; consistent with viral URI.
        - Supportive care, fluids
        - Tylenol/Motrin PRN

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

ADHD
Stable on Vyvanse 30mg PO daily; parent reports good focus and behavior at school.
        - Continue Vyvanse 30mg PO daily

Acute Otitis Media
Right TM bulging and erythematous; consistent with bacterial AOM.
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d
        - Tylenol/Motrin for pain control

PCMH Reminder

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

Asthma
Improved on Flovent 110mcg 2 puffs BID; symptoms well controlled, albuterol use rare.
        - Step down to Flovent 44mcg 2 puffs BID
        - Continue albuterol PRN
        - Reassess control at next visit

Ankle Sprain
Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain.
        - RICE protocol
        - Ibuprofen 400mg PO q6h PRN
        - Weight bearing as tolerated

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic in 3 months or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section.

For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation.

[Problem/Diagnosis Name]
[Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled.]
        - [Plan bullet: brief action, adjustment, or follow-up item]
        - [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.]

If preventive care or health maintenance discussed:
"All screening questions, past medical history, social history, medications, allergies, and preventive care needs reviewed and addressed appropriately. Age-appropriate counseling provided. Patient questions addressed."

If any acute illness discussed:
"Recommended supportive care as appropriate. Return precautions given including worsening symptoms, new symptoms, failure to improve within expected timeframe, and other concerns. Patient expressed understanding and agreement with treatment plan."

If any injury or musculoskeletal complaint discussed:
"Recommended supportive care with analgesics, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If any new prescription medication started:
"Risks, benefits, and alternatives of pharmacologic management discussed. Patient expressed understanding and agreement with treatment plan."

If any controlled substance prescribed or adjusted:
"Risks and benefits of controlled substance use discussed including potential for dependence. Patient expressed understanding and agreement with treatment plan."

If pending lab or imaging results discussed:
"Patient informed that results are pending and will be communicated when available. This problem is moderate risk due to pending results which may necessitate further management."

If patient is at risk for clinical deterioration:
"Patient is at risk for clinical deterioration which would warrant emergency department evaluation or hospital admission. Return precautions and red-flag symptoms reviewed."

If procedure performed:
"Risks, benefits, alternatives, and potential complications of procedure discussed. Informed consent obtained. Patient tolerated procedure well without immediate complications."

---

## Formatting Rules

1. Write the problem/diagnosis name on its own line
2. Assessment: one unlabeled telegraphic prose statement
   - For chronic/ongoing problems: include trend language and current medication/dose
   - For acute/new problems: include key findings and clinical interpretation; omit trend language and medication status
3. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Keep bullets concise (ideally under 10 words per bullet)
7. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
8. Add a blank line between each problem block
9. Add a blank line between the last problem block and any boilerplate text
10. Add a blank line between each boilerplate statement
11. Add a blank line before the follow-up line
12. Only include the follow-up statement once, at the end
13. If follow-up was not explicitly discussed, default to "Follow up as needed"

---

## Few-Shot Examples

Hypertension
Stable on lisinopril 10mg PO daily; BP at goal 128/78 today.
        - Continue lisinopril 10mg PO daily
        - Continue home BP monitoring
        - Recheck BMP at next visit

Follow-Up: Return to clinic in 3 months or as needed.

---

Hypertension
Worsening; BP elevated 158/94 despite lisinopril 10mg PO daily and lifestyle modifications.
        - Increase lisinopril to 20mg PO daily
        - Reinforce low-sodium diet
        - Recheck BP in 4 weeks
        - BMP to reassess renal function

Risks, benefits, and alternatives of pharmacologic management discussed. Patient expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 4 weeks or as needed.

---

Type 2 Diabetes Mellitus
Improved on metformin 1000mg PO BID; A1c down from 8.2% to 7.1%.
        - Continue metformin 1000mg PO BID
        - Continue dietary counseling
        - Recheck A1c in 3 months

Follow-Up: Return to clinic in 3 months or as needed.

---

Type 2 Diabetes Mellitus
Worsening; A1c 9.4% despite metformin 1000mg PO BID and lifestyle modifications.
        - Add empagliflozin 10mg PO daily
        - Diabetes education referral
        - Recheck A1c in 3 months

Risks, benefits, and alternatives of pharmacologic management discussed. Patient expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 3 months or as needed.

---

Major Depressive Disorder
Stable on sertraline 100mg PO daily; PHQ-9 score 6, improved from 14 at last visit.
        - Continue sertraline 100mg PO daily
        - Continue therapy
        - Reassess mood at next visit

Follow-Up: Return to clinic in 3 months or as needed.

---

Major Depressive Disorder
Inadequate response on sertraline 50mg PO daily; PHQ-9 score 18, persistent low mood and anhedonia.
        - Increase sertraline to 100mg PO daily
        - Therapy referral if not already engaged
        - Safety plan reviewed, no SI/HI
        - Reassess in 4 weeks

Risks, benefits, and alternatives of pharmacologic management discussed. Patient expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic in 4 weeks or as needed.

---

Hypertension
Stable on lisinopril 10mg PO daily; BP 130/80.
        - Continue current regimen

Acute Low Back Pain
Acute onset after lifting, paravertebral tenderness L4-L5, no radiculopathy.
        - Ibuprofen 600mg PO q8h PRN x7d
        - Activity modification, avoid heavy lifting
        - Physical therapy referral

Recommended supportive care with analgesics, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic in 3 months or as needed.

---

Atrial Fibrillation
Stable on metoprolol 50mg PO BID and apixaban 5mg PO BID; rate well controlled, no palpitations or dyspnea.
        - Continue metoprolol 50mg PO BID
        - Continue apixaban 5mg PO BID
        - Annual echocardiogram per cardiology

Community-Acquired Pneumonia
Right lower lobe consolidation on CXR; fever, productive cough, and dyspnea x3 days.
        - Amoxicillin-clavulanate 875/125mg PO BID x7d
        - Guaifenesin PRN
        - Encourage fluids and rest
        - Return if worsening dyspnea or persistent fever >48h on antibiotics

Risks, benefits, and alternatives of pharmacologic management discussed. Patient expressed understanding and agreement with treatment plan.

Recommended supportive care as appropriate. Return precautions given including worsening symptoms, new symptoms, failure to improve within expected timeframe, and other concerns. Patient expressed understanding and agreement with treatment plan.

Patient is at risk for clinical deterioration which would warrant emergency department evaluation or hospital admission. Return precautions and red-flag symptoms reviewed.

Follow-Up: Return to clinic in 2 weeks for pneumonia recheck or sooner if worsening.

---

Osteoarthritis, Bilateral Knees
Stable; manageable pain on acetaminophen 650mg PO TID PRN, ambulatory without assistive device.
        - Continue acetaminophen PRN
        - Continue home exercise program
        - Consider PT if symptoms progress

Hypothyroidism
Stable on levothyroxine 75mcg PO daily; TSH 2.4, within goal range.
        - Continue levothyroxine 75mcg PO daily
        - Recheck TSH in 6 months

Follow-Up: Return to clinic in 6 months or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning.

[Problem/Diagnosis Name]
- [A very brief bullet point summarizing a key finding, action, or follow-up plan]
- [Each point should be a separate bullet, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Use a hyphen (-) for all bullets
2. Indent all bullets with 8 spaces
3. Write all bullet points in extremely brief, professional shorthand phrases
4. Keep bullets concise (ideally under 10 words per bullet)
5. Use standard medical abbreviations (RTC, PRN, BID, etc.)
6. Only include the follow-up statement once.

---

## Few-Shot Examples

Asthma
        - Flovent 44mcg 2 puff BID started
        - Continue albuterol PRN
        - Use spacer

Follow-Up: Return to clinic in 3 months or as needed.

---

Well Child Check
        - Growing and developing well
        - Reviewed anticipatory guidance

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

Vomiting, mild dehydration
        - NDNT on exam with MMM
        - Zofran PRN, pedialyte, Tylenol, Motrin

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

ADHD
        - Concerta 27mg not effective
        - Transition to Vyvanse 20mg PO daily

PCMH Reminder

Follow-Up: Return to clinic in one month.

---

Viral URI
        - Supportive care, fluids
        - Declined COVID test

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Viral URI
        - Supportive care, fluids
        - Tylenol/Motrin PRN

Acute Otitis Media
        - Right TM bulging, erythematous
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d
        - Pain control with Tylenol/Motrin

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC PRN

---

Ankle Sprain
        - Left lateral ankle tenderness, no instability
        - RICE protocol
        - Ibuprofen 400mg PO q6h PRN
        - Weight bearing as tolerated

Pharyngitis
        - Rapid strep negative, throat culture pending
        - Symptomatic care with throat lozenges
        - Will call with results if positive

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: RTC PRN or for strep results

---

Well Child Check
        - Growing and developing well
        - Vaccines UTD
        - Reviewed anticipatory guidance

Viral URI
        - Mild rhinorrhea, no fever
        - Supportive care, fluids
        - Tylenol/Motrin PRN

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC next WCC or PRN

Reformat the Assessment & Plan into a structured, problem‑oriented format. The output should be extremely concise for rapid scanning. For each problem, write exactly one paragraph with two unlabeled sentences in this order: (1) an assessment sentence that gives the primary rationale for the medical decisions made; (2) a plan sentence listing testing, treatments, and referrals. Use tight, grammatical, telegraphic prose. After all problem paragraphs, write a single combined follow‑up sentence covering timing and key return precautions for the visit as a whole.

[Problem/Diagnosis Name]
[Paragraph: two sentences — Assessment (rationale) → Plan (tests/treatments/referrals).]

[Combined follow‑up sentence for the visit.]

---

## Conditional Boilerplate Text
[Insert after the problem paragraphs and before the follow‑up sentence when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules
1. One paragraph per problem, containing exactly two sentences: assessment → plan.
2. No bullets or labels inside problem blocks.
3. Keep prose grammatical yet highly concise (telegraphic style allowed).
4. Use standard abbreviations (PRN, BID, PO, RTC, WOB, etc.).
5. Leave one blank line between problem paragraphs and before any boilerplate text.
6. Write one combined follow-up sentence at the very end of the note, after all problem blocks and boilerplate.
7. If follow‑up was not explicitly discussed, default to: "Follow up as needed; return for worsening symptoms or concerns."

---

## Few-Shot Examples

Asthma
Mild persistent asthma with current flare and daily albuterol use. Start Flovent 44 mcg 2 puffs BID with spacer and continue albuterol PRN; no testing or referrals today.

Follow up in 3 months or as needed.

---

Well Child Check
Normal growth and development; no acute concerns raised today. Provide age‑appropriate anticipatory guidance; forms/labs/immunizations reviewed as needed.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Return to clinic at next well child check or as needed.

---

Vomiting, mild dehydration
Acute vomiting with mild dehydration; exam NDNT with MMM. Give Zofran PRN, oral rehydration with Pedialyte, and Tylenol/Motrin as needed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Return to clinic as needed.

---

ADHD
ADHD with suboptimal control on Concerta 27 mg daily. Transition to Vyvanse 20 mg PO daily and monitor response.

PCMH Reminder

Return to clinic in one month.

---

Viral URI
Symptoms consistent with uncomplicated viral URI; no fever noted today. Provide supportive care with fluids and antipyretics/analgesics PRN; patient declined COVID test.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Return to clinic as needed.

---

Viral URI
Rhinorrhea and cough consistent with viral URI without red flags. Provide supportive care with fluids and Tylenol/Motrin PRN; no testing planned.

Acute Otitis Media
Right TM bulging and erythematous consistent with bacterial AOM. Start amoxicillin 400 mg/5 mL, 8 mL PO BID x10 days and use Tylenol/Motrin for pain.

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

RTC PRN.

---

Ankle Sprain
Left lateral ankle tenderness without instability, consistent with mild sprain. Use RICE protocol, ibuprofen 400 mg PO q6h PRN, and weight bearing as tolerated.

Pharyngitis
Sore throat with rapid strep negative and throat culture pending. Provide symptomatic care with throat lozenges; will notify if culture positive.

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Return to clinic PRN or for strep results.

---

Well Child Check
Normal growth and development; vaccines UTD; anticipatory guidance reviewed. Continue routine care and counseling; no acute interventions needed.

Viral URI
Mild rhinorrhea without fever, consistent with uncomplicated viral URI. Supportive care with fluids and Tylenol/Motrin PRN; no testing planned.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

RTC next WCC or PRN.

Reformat the assessment and plan into a structured, problem-oriented format with clear visual hierarchy. For each problem, organize the content into labeled subsections: Assessment, Plan, and Next Steps. Include only sections for which content was discussed; omit unused sections entirely.

[Problem/Diagnosis Name]

Assessment:
- [Bullet points summarizing diagnostic reasoning and clinical context]
- [Use formal medical terminology]

Plan:
- [Immediate interventions, medications, procedures, and orders]
- [Each action item as a separate bullet]

Next Steps:
- [Conditional planning: "If [symptom/test], then [action]"]
- [Follow-up intervals and return precautions]
- [Monitoring parameters]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Write the problem/diagnosis name on its own line
2. Label each subsection (Assessment, Plan, Next Steps) on its own line
3. Use a hyphen (-) for all bullets
4. Indent all bullets with 8 spaces
5. Write content in clear, professional phrases using formal medical terminology
6. Use "reassuring" rather than "normal" when appropriate
7. Keep bullets concise (ideally under 15 words per bullet)
8. No abbreviations except standard medical ones (BID, mcg, PRN, etc.)
9. Include only sections actually discussed; omit unused sections entirely
10. Insert a blank line between problems when multiple diagnoses exist
11. Only include the follow-up statement once, at the end
12. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma

Assessment:
        - Mild persistent asthma with current flare
        - Albuterol use multiple times per week
        - Exam reassuring with clear breath sounds today

Plan:
        - Flovent 44mcg 2 puffs BID with spacer started
        - Continue albuterol as rescue inhaler
        - Asthma action plan provided to family

Next Steps:
        - Return sooner for increased rescue use, nighttime symptoms, or respiratory distress
        - If control remains poor, consider montelukast or referral to Allergy

Follow-Up: Return to clinic in 3 months or as needed.

---

Well Child Check

Assessment:
        - Healthy 4yo with normal growth and development
        - No acute concerns raised today

Plan:
        - Vaccines administered per schedule
        - Age-appropriate anticipatory guidance reviewed

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

Vomiting, mild dehydration

Assessment:
        - Acute vomiting with mild dehydration
        - Tolerating small sips with moist mucous membranes
        - Abdomen non-distended, non-tender on exam

Plan:
        - Zofran PRN for nausea
        - Oral rehydration with Pedialyte
        - Tylenol and Motrin as needed for comfort

Next Steps:
        - Go to ED if unable to maintain oral hydration
        - Return for worsening vomiting, lethargy, or decreased urine output

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

ADHD

Assessment:
        - Ongoing ADHD with inadequate symptom control on Concerta 27mg
        - Parent and teacher report persistent inattention and impulsivity
        - Growth and vitals reassuring today

Plan:
        - Discontinue Concerta 27mg
        - Start Vyvanse 20mg PO daily
        - Provide teacher Vanderbilt forms for monitoring

Next Steps:
        - Return sooner for significant appetite suppression, sleep disturbance, or mood changes

PCMH Reminder

Follow-Up: Return to clinic in one month.

---

Viral URI
 
Assessment:
        - Rhinorrhea and cough consistent with viral URI
        - No fever or red flags on exam today

Plan:
        - Supportive care with fluids and rest
        - Tylenol and Motrin PRN for comfort

Acute Otitis Media

Assessment:
        - Right tympanic membrane bulging and erythematous
        - Consistent with bacterial acute otitis media

Plan:
        - Amoxicillin 400mg/5mL, 8mL PO BID x10 days
        - Tylenol and Motrin for pain control

Next Steps:
        - Return if symptoms worsen or do not improve within 48-72 hours

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Ankle Sprain

Assessment:
        - Left lateral ankle tenderness without instability
        - Consistent with mild lateral ankle sprain

Plan:
        - RICE protocol initiated
        - Ibuprofen 400mg PO q6h PRN for pain and swelling
        - Weight bearing as tolerated

Next Steps:
        - Return if pain worsens, swelling increases, or unable to bear weight
        - If not improving in one week, consider X-ray

Pharyngitis

Assessment:
        - Sore throat with rapid strep negative
        - Throat culture pending; cannot exclude strep at this time

Plan:
        - Symptomatic care with throat lozenges and OTC analgesics

Next Steps:
        - Will contact family if culture returns positive to initiate antibiotics

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic as needed and pending strep culture results.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose statement capturing the key findings and clinical interpretation, then list the plan as brief bullet points beneath it. Keep the assessment statement as short as possible. Do not label either section.

[Problem/Diagnosis Name]
[Assessment: concise telegraphic prose, unlabeled.]
        - [Plan bullet: brief action, medication, or follow-up item]
        - [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Write the problem/diagnosis name on its own line
2. Assessment: one unlabeled telegraphic prose sentence capturing key findings and clinical interpretation
3. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Keep bullets concise (ideally under 10 words per bullet)
7. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
8. Only include the follow-up statement once, at the end
9. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma
Persistent symptoms despite albuterol consistent with inadequately controlled asthma.
        - Flovent 44mcg 2 puffs BID started
        - Continue albuterol PRN
        - Use spacer
        - Reassess control at follow-up

Follow-Up: Return to clinic in 3 months or as needed.

---

Well Child Check
Healthy 4yo, normal growth, development, and exam; no concerns.
        - Vaccines UTD
        - Anticipatory guidance reviewed

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

Vomiting, mild dehydration
Tolerating small sips, MMM, NDNT; consistent with mild dehydration, no IV fluids needed at this time.
        - Zofran PRN
        - Oral rehydration with Pedialyte
        - Tylenol/Motrin PRN
        - ED if unable to maintain hydration

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

ADHD
Inadequate symptom control on Concerta 27mg per parent and teacher report.
        - Discontinue Concerta 27mg
        - Start Vyvanse 20mg PO daily
        - Reassess at one-month follow-up

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Viral URI
Consistent with viral URI; family declined COVID testing.
        - Supportive care, fluids
        - OTC medications PRN

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Viral URI
Mild rhinorrhea, no fever; consistent with viral URI.
        - Supportive care, fluids
        - Tylenol/Motrin PRN

Acute Otitis Media
Right TM bulging and erythematous; consistent with bacterial AOM.
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d
        - Tylenol/Motrin for pain control

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Ankle Sprain
Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain.
        - RICE protocol
        - Ibuprofen 400mg PO q6h PRN
        - Weight bearing as tolerated

Pharyngitis
Rapid strep negative, throat culture pending; cannot exclude strep at this time.
        - Symptomatic care with lozenges, OTC analgesics
        - Will call with results if culture positive to initiate antibiotics

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic as needed and pending strep culture results.

---

Well Child Check
Healthy 3yo, normal growth, development, and exam; no acute concerns.
        - Vaccines UTD
        - Anticipatory guidance reviewed

Viral URI
Mild rhinorrhea, no fever; consistent with viral URI.
        - Supportive care, fluids
        - Tylenol/Motrin PRN

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic at next well child check or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning. Use numbered plan items instead of bullet points.

[Write a one-liner (<20 words) in telegraphic clinical language that states the reason for the visit, the key management decision and its main clinical rationale.]

[Problem/Diagnosis Name]
1. [A very brief numbered item summarizing a key finding, action, or follow-up plan]
2. [Each point should be a separate numbered item, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after the numbered list when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Use sequential numbers (1. 2. 3.) for all plan items — not hyphens or bullets
2. Indent all numbered items with 8 spaces
3. Restart numbering at 1 for each new problem
4. Write all items in extremely brief, professional shorthand phrases
5. Keep items concise (ideally under 10 words per item)
6. Use standard medical abbreviations (RTC, PRN, BID, etc.)
7. If patient age is unknown, omit age from the one-liner
8. Only include one-liner and follow-up statement once

---

## Few-Shot Examples

8yo with acute asthma exacerbation; starting ICS given persistent symptoms despite albuterol.

Asthma
        1. Flovent 44mcg 2 puff BID started
        2. Continue albuterol PRN
        3. Use spacer

Follow-Up: Return to clinic in 3 months or as needed.

---

4yo WCC; normal growth/development, no concerns identified.

Well Child Check
        1. Growing and developing well
        2. Reviewed anticipatory guidance

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

2yo with vomiting and mild dehydration; giving Zofran and oral rehydration given tolerating small sips.

Vomiting, mild dehydration
        1. NDNT on exam with MMM
        2. Zofran PRN, pedialyte, Tylenol, Motrin

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

10yo with ADHD; switching from Concerta to Vyvanse given inadequate symptom control.

ADHD
        1. Concerta 27mg not effective
        2. Transition to Vyvanse 20mg PO daily

PCMH Reminder

Follow-Up: Return to clinic in one month.

---

Patient with likely viral URI; supportive care recommended, family declined COVID testing.

Viral URI
        1. Supportive care, fluids
        2. Declined COVID test

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

5yo with viral URI and acute otitis media; starting amoxicillin given bulging TM.

Viral URI
        1. Supportive care, fluids
        2. Tylenol/Motrin PRN

Acute Otitis Media
        1. Right TM bulging, erythematous
        2. Amoxicillin 400mg/5mL, 8mL PO BID x10d
        3. Pain control with Tylenol/Motrin

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC PRN

---

12yo with ankle sprain and pharyngitis; strep test pending, started supportive care.

Ankle Sprain
        1. Left lateral ankle tenderness, no instability
        2. RICE protocol
        3. Ibuprofen 400mg PO q6h PRN
        4. Weight bearing as tolerated

Pharyngitis
        1. Rapid strep negative, throat culture pending
        2. Symptomatic care with throat lozenges
        3. Will call with results if positive

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: RTC PRN or for strep results

---

3yo WCC with concurrent URI symptoms; addressed preventive care and acute illness.

Well Child Check
        1. Growing and developing well
        2. Vaccines UTD
        3. Reviewed anticipatory guidance

Viral URI
        1. Mild rhinorrhea, no fever
        2. Supportive care, fluids
        3. Tylenol/Motrin PRN

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC next WCC or PRN

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning.

[Write a one-liner (<20 words) in telegraphic clinical language that states the reason for the visit, the key management decision and its main clinical rationale.]

[Problem/Diagnosis Name]
- [A very brief bullet point summarizing a key finding, action, or follow-up plan]
- [Each point should be a separate bullet, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable.]

If trigger discussed:
"Your dot phrase here.  You may need to experiment some with different trigger words that will fire consistently for you but terms you know you say in the room or ICD-10 codes are both good places to start. Remember there is a balance to the convenience of automatically including your favorite dot phrases vs giving the model a wall of essentially unrelated text that it parses for instructions degrading performance.  Start with your top 3-5 and then include more if desired after testing."

---

## Formatting Rules

1. Use a hyphen (-) for all bullets
2. Indent all bullets with 8 spaces
3. Write all bullet points in extremely brief, professional shorthand phrases
4. Keep bullets concise (ideally under 10 words per bullet)
5. Use standard medical abbreviations (RTC, PRN, BID, etc.)
6. If patient age is unknown, omit age from the one-liner
7. Only include one-liner and follow-up statement once.

---

## Few-Shot Examples (Remember these need to be made your own for best effect.)

8yo with diagnosis; starting medication given persistent symptoms despite previous treatment.

Asthma
        - Medication started
        - Continue other medication PRN
        - Use spacer

Follow-Up: Return to clinic in 3 months or as needed.

---

4yo WCC; normal growth/development, no concerns identified.

Well Child Check
        - Growing and developing well
        - Reviewed anticipatory guidance

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

2yo with vomiting and mild dehydration; giving Zofran and oral rehydration given tolerating small sips.

Vomiting, mild dehydration
        - NDNT on exam with MMM
        - Zofran PRN, pedialyte, Tylenol, Motrin

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

10yo with ADHD; switching from Concerta to Vyvanse given inadequate symptom control.

ADHD
        - Concerta 27mg not effective
        - Transition to Vyvanse 20mg PO daily

PCMH Reminder

Follow-Up: Return to clinic in one month.

---

Patient with likely viral URI; supportive care recommended, family declined COVID testing.

Viral URI
        - Supportive care, fluids
        - Declined COVID test

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

5yo with viral URI and acute otitis media; starting amoxicillin given bulging TM. 
Viral URI
        - Supportive care, fluids 
        - Tylenol/Motrin PRN 

Acute Otitis Media 
        - Right TM bulging, erythematous 
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d 
        - Pain control with Tylenol/Motrin 

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Follow-Up: RTC PRN 

---

12yo with ankle sprain and pharyngitis; strep test pending, started supportive care. 

Ankle Sprain 
        - Left lateral ankle tenderness, no instability 
        - RICE protocol 
        - Ibuprofen 400mg PO q6h PRN 
        - Weight bearing as tolerated 

Pharyngitis 
        - Rapid strep negative, throat culture pending 
        - Symptomatic care with throat lozenges 
        - Will call with results if positive

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. 

Follow-Up: RTC PRN or for strep results

---

3yo WCC with concurrent URI symptoms; addressed preventive care and acute illness.

Well Child Check 
        - Growing and developing well 
        - Vaccines UTD 
        - Reviewed anticipatory guidance 

Viral URI 
        - Mild rhinorrhea, no fever 
        - Supportive care, fluids 
        - Tylenol/Motrin PRN 

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Follow-Up: RTC next WCC or PRN 

---

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning.

[Write a one-liner (<20 words) in telegraphic clinical language that states the reason for the visit, the key management decision and its main clinical rationale.]

[Problem/Diagnosis Name]
- [A very brief bullet point summarizing a key finding, action, or follow-up plan]
- [Each point should be a separate bullet, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Use a hyphen (-) for all bullets
2. Indent all bullets with 8 spaces
3. Write all bullet points in extremely brief, professional shorthand phrases
4. Keep bullets concise (ideally under 10 words per bullet)
5. Use standard medical abbreviations (RTC, PRN, BID, etc.)
6. If patient age is unknown, omit age from the one-liner
7. Only include one-liner and follow-up statement once.

---

## Few-Shot Examples

8yo with acute asthma exacerbation; starting ICS given persistent symptoms despite albuterol.

Asthma
        - Flovent 44mcg 2 puff BID started
        - Continue albuterol PRN
        - Use spacer

Follow-Up: Return to clinic in 3 months or as needed.

---

4yo WCC; normal growth/development, no concerns identified.

Well Child Check
        - Growing and developing well
        - Reviewed anticipatory guidance

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

2yo with vomiting and mild dehydration; giving Zofran and oral rehydration given tolerating small sips.

Vomiting, mild dehydration
        - NDNT on exam with MMM
        - Zofran PRN, pedialyte, Tylenol, Motrin

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

10yo with ADHD; switching from Concerta to Vyvanse given inadequate symptom control.

ADHD
        - Concerta 27mg not effective
        - Transition to Vyvanse 20mg PO daily

PCMH Reminder

Follow-Up: Return to clinic in one month.

---

Patient with likely viral URI; supportive care recommended, family declined COVID testing.

Viral URI
        - Supportive care, fluids
        - Declined COVID test

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

5yo with viral URI and acute otitis media; starting amoxicillin given bulging TM. 
Viral URI
        - Supportive care, fluids 
        - Tylenol/Motrin PRN 

Acute Otitis Media 
        - Right TM bulging, erythematous 
        - Amoxicillin 400mg/5mL, 8mL PO BID x10d 
        - Pain control with Tylenol/Motrin 

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Follow-Up: RTC PRN 

---

12yo with ankle sprain and pharyngitis; strep test pending, started supportive care. 

Ankle Sprain 
        - Left lateral ankle tenderness, no instability 
        - RICE protocol 
        - Ibuprofen 400mg PO q6h PRN 
        - Weight bearing as tolerated 

Pharyngitis 
        - Rapid strep negative, throat culture pending 
        - Symptomatic care with throat lozenges 
        - Will call with results if positive

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. 

Follow-Up: RTC PRN or for strep results

---

3yo WCC with concurrent URI symptoms; addressed preventive care and acute illness.

Well Child Check 
        - Growing and developing well 
        - Vaccines UTD 
        - Reviewed anticipatory guidance 

Viral URI 
        - Mild rhinorrhea, no fever 
        - Supportive care, fluids 
        - Tylenol/Motrin PRN 

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. 

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. 

Follow-Up: RTC next WCC or PRN 

---

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write two concise prose statements: first, a brief clinical assessment capturing the key findings and your interpretation; second, a brief plan statement describing what is being done. Do not label these lines. Keep each statement as short as possible without losing essential clinical meaning. Do not use bullet points.

[Problem/Diagnosis Name]
[Assessment: key findings and clinical interpretation, unlabeled.]
[Plan: what is being done, unlabeled. May include forward-directed thinking such as contingency plans or follow-up expectations where naturally applicable.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Write the problem/diagnosis name on its own line, followed by two unlabeled prose statements on separate lines
2. Assessment line first: key findings and clinical interpretation
3. Plan line second: management decisions and forward-directed thinking
4. No bullet points, no labels, no headers within the problem block
5. Keep each line as brief as possible; length should match complexity of the problem
6. Use standard medical abbreviations (BID, PRN, PO, etc.)
7. Only include the follow-up statement once, at the end
8. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma
Persistent symptoms despite albuterol consistent with inadequately controlled asthma.
Starting Flovent 44mcg 2 puffs BID with spacer; continue albuterol PRN; will reassess control at follow-up.

Follow-Up: Return to clinic in 3 months or as needed.

---

Well Child Check
Healthy 4yo with normal growth, development, and exam; no concerns identified.
Anticipatory guidance reviewed, vaccines UTD, all parent questions addressed.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: Return to clinic at next well child check or as needed.

---

Vomiting, mild dehydration
Tolerating small sips with moist mucous membranes and non-distended abdomen, consistent with mild dehydration without need for IV fluids at this time.
Zofran and oral rehydration with Pedialyte recommended; Tylenol/Motrin PRN; family instructed to go to ED if unable to maintain hydration.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

ADHD
Inadequate symptom control on Concerta 27mg per parent and teacher report.
Transitioning to Vyvanse 20mg PO daily; will reassess response at one-month follow-up.

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Viral URI
Presentation consistent with viral upper respiratory infection; family declined COVID testing.
Supportive care with fluids and OTC medications recommended; return precautions reviewed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Viral URI
Mild rhinorrhea without fever consistent with viral URI.
Supportive care with fluids and Tylenol/Motrin as needed.

Acute Otitis Media
Right TM bulging and erythematous consistent with bacterial AOM.
Amoxicillin 400mg/5mL 8mL PO BID x10d started; Tylenol/Motrin for pain control; return precautions given for worsening or failure to improve.

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Ankle Sprain
Left lateral ankle with tenderness but no instability, consistent with mild lateral ankle sprain.
RICE protocol initiated; ibuprofen 400mg PO q6h PRN; weight bearing as tolerated; return precautions given for increasing pain or swelling.

Pharyngitis
Rapid strep negative with throat culture pending; cannot exclude strep at this time.
Symptomatic care with lozenges and OTC analgesics for now; family to be contacted if culture returns positive to initiate antibiotics.

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic as needed and pending strep culture results.

---

Well Child Check
Healthy 3yo with normal growth, development, and exam; no acute concerns.
Vaccines UTD; anticipatory guidance reviewed; all parent questions addressed.

Viral URI
Mild rhinorrhea without fever consistent with viral URI.
Supportive care with fluids and Tylenol/Motrin as needed; return precautions reviewed.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic at next well child check or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section.

For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation.

[Problem/Diagnosis Name]
[Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled.]
- [Plan bullet: brief action, adjustment, or follow-up item]
- [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

Conditional Boilerplate Text
[Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.]

If two or more management options were weighed and one chosen with patient/caregiver involvement, write one sentence beginning with "Considered" and containing the phrase "after shared decision-making conversation including risks, benefits, and alternatives" drawn from visit details. Place after relevant problem's plan bullets.

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Answered all questions."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.  Answered all questions."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.  Answered all questions."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

Formatting Rules
Write the problem/diagnosis name on its own line
Assessment: one unlabeled telegraphic prose statement
For chronic/ongoing problems: include trend language and current medication/dose
For acute/new problems: include key findings and clinical interpretation; omit trend language and medication status
Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
Use a hyphen (-) for all bullets
Indent all bullets with 8 spaces
Keep bullets concise (ideally under 10 words per bullet)
Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
Add a blank line between each problem block
Add a blank line between the last problem block and any boilerplate text
Add a blank line between each boilerplate statement
Add a blank line before the follow-up line
Only include the follow-up statement once, at the end
If follow-up was not explicitly discussed, default to "Return to clinic as needed"
Few-Shot Examples
Asthma
Stable on Flovent 44mcg 2 puffs BID with spacer; albuterol use minimal.
- Continue Flovent 44mcg 2 puffs BID
- Continue albuterol PRN
- Reassess control at next visit

Follow-Up: Return to clinic in 3 months or as needed.

Asthma
Worsening; persistent symptoms despite Flovent 44mcg 2 puffs BID and albuterol PRN.
- Step up to Flovent 110mcg 2 puffs BID
- Continue albuterol PRN
- Return sooner if symptoms not improving

Follow-Up: Return to clinic in 6 weeks or as needed.

ADHD
Improved on Vyvanse 20mg PO daily per parent and teacher report; no side effects.
- Continue Vyvanse 20mg PO daily
- Reassess at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

ADHD
Inadequate symptom control on Concerta 27mg PO daily per parent and teacher report.
- Transition to Vyvanse 20mg PO daily
- Reassess response at one-month follow-up

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

Obesity
Stable; BMI unchanged since last visit, currently on dietary counseling and activity plan.
- Continue dietary counseling
- Encourage 60 min physical activity daily
- Recheck BMI at next visit

PCMH Reminder

Follow-Up: Return to clinic in 3 months or as needed.

Asthma
Stable on Flovent 44mcg 2 puffs BID; albuterol use minimal.
- Continue current regimen

Viral URI
Mild rhinorrhea, no fever; consistent with viral URI.
- Supportive care, fluids
- Tylenol/Motrin PRN

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Answered all questions.

Follow-Up: Return to clinic in 3 months or as needed.

ADHD
Stable on Vyvanse 30mg PO daily; parent reports good focus and behavior at school.
- Continue Vyvanse 30mg PO daily

Acute Otitis Media
Right TM bulging and erythematous; consistent with bacterial AOM.
- Amoxicillin 400mg/5mL, 8mL PO BID x10d
- Tylenol/Motrin for pain control

PCMH Reminder

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Answered all questions.

Follow-Up: Return to clinic in 3 months or as needed.

Asthma
Improved on Flovent 110mcg 2 puffs BID; symptoms well controlled, albuterol use rare.
- Step down to Flovent 44mcg 2 puffs BID
- Continue albuterol PRN
- Reassess control at next visit

Ankle Sprain
Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain.
- RICE protocol
- Ibuprofen 400mg PO q6h PRN
- Weight bearing as tolerated

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Answered all questions.

Follow-Up: Return to clinic in 3 months or as needed.

Abdominal Pain
RLQ tenderness, no rebound; labs and exam not convincingly surgical at this time.
- Supportive care, clear liquids
- Serial abdominal exams
- Close ED return precautions

Considered CT abdomen/pelvis to evaluate for appendicitis, but after shared decision-making conversation including risks, benefits, and alternatives, plan to pursue watchful waiting with close return precautions and reassessment tomorrow morning.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Answered all questions.

Follow-Up: Return to clinic tomorrow morning or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write a single concise blurb in the style of a well-trained resident's oral presentation: state the key findings and clinical assessment, the treatment plan, and any forward-directed thinking such as return precautions, contingency plans, or follow-up expectations. The blurb may be one sentence or a few short sentences, but must remain as brief as possible without losing essential clinical meaning.

[Problem/Diagnosis Name]
[Resident-style blurb: assessment + plan + forward-directed thinking.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blurbs and before the follow-up line when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Write the problem/diagnosis name followed by the blurb written below on a new line.
2. Write the blurb as flowing prose — no bullet points
3. Keep each blurb as concise as possible; length should match complexity of the problem
4. Use standard medical abbreviations (BID, etc.)
5. Include forward-directed thinking (return precautions, contingency plans, follow-up expectations) within the blurb itself where naturally applicable
6. Only include the follow-up statement once, at the end
7. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma
Persistent symptoms despite albuterol consistent with inadequately controlled asthma; starting Flovent 44mcg 2 puffs BID with spacer, continue albuterol as needed, and will reassess control at follow-up.

Follow-Up: Return to clinic in 3 months or as needed.

---

Well Child Check
Healthy 4yo with normal growth, development, and exam; all anticipatory guidance reviewed, vaccines UTD, no concerns identified.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: At next well child check or as needed.

---

Vomiting, mild dehydration
Tolerating small sips with moist mucous membranes and non-distended abdomen on exam, consistent with mild dehydration without need for IV fluids at this time; Zofran and oral rehydration with Pedialyte recommended, with Tylenol/Motrin as needed, and family instructed to go to ED if unable to maintain hydration.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: Return to clinic as needed.

---

ADHD
Inadequate symptom control on Concerta 27mg per parent and teacher report; transitioning to Vyvanse 20mg PO daily and will reassess response at one-month follow-up.

PCMH Reminder

Follow-Up: Return to clinic in one month or as needed.

---

Viral URI
Presentation consistent with viral upper respiratory infection; supportive care with fluids and OTC medications recommended, family declined COVID testing, return precautions reviewed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Viral URI
Mild rhinorrhea without fever consistent with viral URI; supportive care with fluids and Tylenol/Motrin as needed, return precautions reviewed.

Acute Otitis Media
Right TM bulging and erythematous consistent with bacterial AOM; started amoxicillin 400mg/5mL 8mL PO BID x10d with Tylenol/Motrin for pain control, return precautions given for worsening or failure to improve.

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Return to clinic as needed.

---

Ankle Sprain
Left lateral ankle with tenderness but no instability, consistent with mild sprain; RICE protocol initiated with ibuprofen 400mg PO q6h as needed, weight bearing as tolerated, return precautions given for increasing pain or swelling.

Pharyngitis
Rapid strep negative with throat culture pending; symptomatic care with lozenges and OTC analgesics for now, family to be contacted if culture returns positive to initiate antibiotics.

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: Return to clinic as needed and pending strep culture results.

---

Well Child Check
Healthy 3yo with normal growth, development, and exam; vaccines UTD, anticipatory guidance reviewed, no acute concerns.

Viral URI
Mild rhinorrhea without fever consistent with viral URI; supportive care with fluids and Tylenol/Motrin as needed, return precautions reviewed.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: Next well child check or as needed.

Reformat the assessment and plan into a system-based format. Organize the output by organ system rather than by individual problem or diagnosis. Cover all of the following systems in every note in this exact order: Respiratory, Cardiovascular, FEN/GI, ID, HO, Neuro, Psych, Social, Dispo. For systems that are stable or not clinically relevant, write a simple one-line negative statement. For systems with active issues, write a brief assessment followed by concise bulleted plan items.

Begin with a brief summary statement (<2 sentences) stating the patient identifier, the primary reason for admission or visit, and hospital day if applicable.

[Brief summary statement.]

Respiratory: [Assessment and plan, or simple negative statement]
Cardiovascular: [Assessment and plan, or simple negative statement]
FEN/GI: [Assessment and plan, or simple negative statement]
ID: [Assessment and plan, or simple negative statement]
HO: [Assessment and plan, or simple negative statement]
Neuro: [Assessment and plan, or simple negative statement]
Psych: [Assessment and plan, or simple negative statement]
Social: [Assessment and plan, or simple negative statement]
Dispo: [Assessment and plan, or simple negative statement]

---

## Formatting Rules

1. Always include all 9 systems in the order listed above, even if stable
2. For stable/non-relevant systems, write one brief negative statement on the same line (e.g., "Respiratory: Stable on room air")
3. For active systems, write the system name on its own line followed by a brief assessment statement, then bulleted plan items beneath
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Keep bullets concise (ideally under 10 words per bullet)
7. Use standard medical abbreviations (BID, PRN, PO, IV, etc.)
8. The summary statement should be telegraphic and concise
9. Never fabricate or infer information not present in the source text

---

## Few-Shot Examples

### Example 1: Pediatric admission for asthma exacerbation

8yo admitted for acute asthma exacerbation with hypoxia requiring supplemental O2; HD#2.

Respiratory:
Asthma exacerbation, improved on continuous albuterol, now spacing to q4h; weaning O2.
        - Albuterol neb q4h
        - Wean O2 to maintain SpO2 >92%
        - Start Flovent 44mcg 2 puffs BID once spacing to q6h
        - Continue monitoring respiratory status

Cardiovascular: Hemodynamically stable, no concerns.

FEN/GI: Tolerating regular diet, adequate PO intake.

ID: Afebrile, no signs of infection.

HO: No hematologic or oncologic concerns.

Neuro: Alert, age-appropriate, no focal deficits.

Psych: Appropriate affect, coping well with hospitalization.

Social: Parents at bedside, family meeting completed. School notified of absence.

Dispo:
Likely discharge tomorrow if tolerating albuterol q6h on room air.
        - Discharge with Flovent 44mcg 2 puffs BID, albuterol PRN
        - Asthma action plan to family
        - Follow-up with PCP in 1 week

---

### Example 2: Adult ED visit for pneumonia

65yo presenting with fever, cough, and hypoxia; CXR with RLL consolidation consistent with community-acquired pneumonia.

Respiratory:
Right lower lobe pneumonia on CXR; requiring 2L NC to maintain SpO2 >94%.
        - Supplemental O2 2L NC
        - Chest PT and incentive spirometry
        - Monitor respiratory status for clinical deterioration

Cardiovascular: Sinus tachycardia, likely demand; no acute cardiac concerns.

FEN/GI:
Mild dehydration on presentation; tolerating sips.
        - NS bolus 1L, then D5 1/2NS at 100mL/hr
        - Advance diet as tolerated

ID:
Febrile to 39.1C; WBC 15.2 with left shift. Blood cultures drawn.
        - Ceftriaxone 1g IV daily + azithromycin 500mg IV daily
        - Monitor fever curve and WBC trend
        - Follow blood cultures

HO: No hematologic or oncologic concerns.

Neuro: Alert and oriented x4, no focal deficits.

Psych: Anxious about hospitalization; reassurance provided.

Social: Lives alone; daughter is emergency contact and updated. Will need to assess home safety prior to discharge.

Dispo:
Admit to medicine for IV antibiotics and O2 monitoring.
        - Anticipated 2-3 day stay
        - Transition to PO antibiotics when afebrile x24h and tolerating PO
        - Follow-up with PCP within 1 week of discharge

---

### Example 3: Pediatric admission for dehydration with multiple active systems

2yo admitted for dehydration secondary to viral gastroenteritis; HD#1.

Respiratory: Stable on room air, no WOB.

Cardiovascular: Mild tachycardia consistent with dehydration, improving with fluids.

FEN/GI:
Moderate dehydration with vomiting and diarrhea x3 days; tolerating small sips, sunken eyes improving.
        - D5 1/2NS + 20mEq KCl/L at 1.5x maintenance
        - Zofran 2mg IV q6h PRN
        - Advance PO with Pedialyte as tolerated
        - Strict I&O, daily weights

ID: Afebrile, stool studies pending. No antibiotics indicated at this time.

HO: No concerns.

Neuro: Alert, interactive, crying with tears after fluid resuscitation.

Psych: Age-appropriate behavior, comforted by parents.

Social: Both parents at bedside, comfortable with plan. Social work not needed at this time.

Dispo:
Continue IV fluids until tolerating adequate PO to maintain hydration.
        - Likely discharge tomorrow if PO challenge successful
        - Discharge with Pedialyte and supportive care instructions
        - Follow-up with PCP in 2-3 days

Reformat the assessment and plan into the most concise format possible. For each problem, write exactly one telegraphic sentence that fuses the assessment and plan together: state the key clinical finding or interpretation, then the action taken, separated by a semicolon. No bullets, no subsections, no headers beyond the problem name. Each problem gets only one line.

[Problem/Diagnosis Name]
[Single sentence: key finding/assessment; action taken/plan.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem lines and before the follow-up line when applicable.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, weight, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Exactly one sentence per problem — no more
2. Use a semicolon to separate assessment from plan within the sentence
3. Write in telegraphic clinical shorthand — omit articles and filler words
4. Use standard medical abbreviations (PRN, BID, PO, RTC, etc.)
5. Keep each sentence as short as possible; aim for under 25 words
6. No bullets, no numbered lists, no subsections
7. Insert a blank line between each problem
8. Only include the follow-up statement once, at the end
9. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

Asthma
Persistent symptoms despite albuterol; starting Flovent 44mcg 2 puffs BID with spacer.

Follow-Up: RTC 3mo or PRN.

---

Well Child Check
Healthy 4yo, normal growth and development; anticipatory guidance reviewed, vaccines UTD.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Follow-Up: RTC next WCC or PRN.

---

Vomiting, mild dehydration
Tolerating sips, MMM, NDNT; Zofran PRN and oral rehydration with Pedialyte.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids.

Follow-Up: RTC PRN.

---

ADHD
Inadequate control on Concerta 27mg per parent/teacher report; transitioning to Vyvanse 20mg PO daily.

PCMH Reminder

Follow-Up: RTC 1mo.

---

Viral URI
Symptoms consistent with viral URI, no red flags; supportive care with fluids, family declined COVID test.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC PRN.

---

Viral URI
Mild rhinorrhea, no fever; supportive care with fluids and Tylenol/Motrin PRN.

Acute Otitis Media
Right TM bulging and erythematous; amoxicillin 400mg/5mL 8mL PO BID x10d, Tylenol/Motrin for pain.

Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC PRN.

---

Ankle Sprain
Left lateral ankle tender, no instability; RICE, ibuprofen 400mg PO q6h PRN, WBAT.

Pharyngitis
Rapid strep negative, culture pending; symptomatic care, will call if positive.

Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve.

Follow-Up: RTC PRN or for strep results.

---

Well Child Check
Healthy 3yo, normal growth and development; vaccines UTD, anticipatory guidance reviewed.

Viral URI
Mild rhinorrhea, no fever; supportive care with fluids and Tylenol/Motrin PRN.

All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed.

Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan.

Follow-Up: RTC next WCC or PRN.

{List all abnormal findings first, organized by system. If no abnormal findings are mentioned for a system, skip it. Use concise formal clinical language.}

GENERAL APPEARANCE: [List abnormal findings if present]  
VITAL SIGNS: [List abnormal findings if present]  
HEENT: [List abnormal findings if present]  
RESPIRATORY: [List abnormal findings if present]  
CARDIOVASCULAR: [List abnormal findings if present]  
GASTROINTESTINAL: [List abnormal findings if present]  
GENITOURINARY: [List abnormal findings if present, prefixed Male or Female]  
LYMPHATIC: [List abnormal findings if present]  
BACK, MUSCULOSKELETAL: [List abnormal findings if present]  
EXTREMITIES: [List abnormal findings if present]  
SKIN: [List abnormal findings if present]  
NEUROLOGICAL: [List abnormal findings if present]  
PSYCHIATRIC: [List abnormal findings if present]  
OTHER OBSERVATIONS: [List abnormal findings if present]  

{Insert a single blank line between abnormal and normal sections}

GENERAL APPEARANCE: "Patient is in no acute distress, well-developed, well nourished, and not ill-appearing." {If GENERAL APPEARANCE mentioned above, then delete this line.}

VITAL SIGNS: "Vitals and nursing note reviewed." {If VITAL SIGNS mentioned above, then delete this line.}

HEENT:  
"Head: Normocephalic and atraumatic." {If HEAD mentioned above, then delete this line.}  
"Eyes: No discharge, EOMI, conjunctiva clear, and PERRL." {If EYES mentioned above, then delete this line.}  
"Ears: TM, canal, and external ears normal bilaterally." {If EARS mentioned above, then delete this line.}  
"Nose: No congestion or rhinorrhea." {If NOSE mentioned above, then delete this line.}  
"Mouth: Mucous membranes moist." {If MOUTH mentioned above, then delete this line.}  
"Pharynx: No erythema, exudate, or tonsillar enlargement." {If PHARYNX mentioned above, then delete this line.}

RESPIRATORY:  
"Effort: No respiratory distress." {If RESPIRATORY EFFORT mentioned above, then delete this line.}  
"Breath sounds: Clear bilaterally. No wheezing or rales." {If BREATH SOUNDS mentioned above, then delete this line.}

CARDIOVASCULAR: "Regular rate and rhythm. No murmurs, gallops, or rubs. Brisk cap refill." {If CARDIOVASCULAR mentioned above, then delete this line.}

GASTROINTESTINAL: "Soft, non-tender, non-distended. No guarding or rebound." {If GASTROINTESTINAL mentioned above, then delete this line.}

GENITOURINARY: [Insert findings (prefixed Male or Female). If no GU exam was verbally described or noted above, write “GU deferred.” Otherwise, include findings. If chaperone was mentioned, document below.]

LYMPHATIC: "No cervical, axillary, or inguinal lymphadenopathy." {If LYMPHATIC mentioned above, then delete this line.}

BACK, MUSCULOSKELETAL: "No abnormal or restricted ROM. No scoliosis or pain with movement." {Only include if BACK, MUSCULOSKELETAL mentioned above; otherwise delete this line.}

EXTREMITIES: "No deformities, cyanosis, or edema." {If EXTREMITIES mentioned above, then delete this line.}

SKIN: "Warm and dry. No rash or lesions." {If SKIN mentioned above, then delete this line.}

NEUROLOGICAL: "Alert and oriented for age. Normal tone and reflexes." {If NEUROLOGICAL mentioned above, then delete this line.}

PSYCHIATRIC: "Mood and affect appropriate. Behavior normal for age." {If PSYCHIATRIC mentioned above, then delete this line.}

OTHER OBSERVATIONS: [Insert any other relevant findings.] {If not mentioned, delete this line.}

Follow-up: [State follow-up timeframe or instructions] {If none specified, then delete this row and its header}

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section. Do not include the diagnosis name — it will be recorded separately in the problem list.

Separate each problem block with a single blank line. Do not add any header, label, or number before each block.

For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation.

---

## Output Structure For Each Problem/Diagnosis

[Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled. Bold this assessment statement.]
- [Plan bullet: brief action, adjustment, or follow-up item]
- [Additional plan bullets as needed]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. All questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

---

## Formatting Rules

1. **Bold formatting** for the assessment statement of each problem
2. **Italicized formatting** for all boilerplate text
3. Do not include the diagnosis name anywhere in the output
4. Do not add any header, label, or number before each problem block
5. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase
6. Use a hyphen (-) for all bullets
7. Keep bullets concise (ideally under 10 words per bullet)
8. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.)
9. Add a blank line between each problem block
10. Only include the follow-up statement once, at the end
11. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

**Stable on Flovent 44mcg 2 puffs BID with spacer; albuterol use minimal.**
- Continue Flovent 44mcg 2 puffs BID
- Continue albuterol PRN
- Reassess control at next visit

Return to clinic in 3 months or as needed.

**Worsening; persistent symptoms despite Flovent 44mcg 2 puffs BID and albuterol PRN.**
- Step up to Flovent 110mcg 2 puffs BID
- Continue albuterol PRN
- Return sooner if symptoms not improving

Return to clinic in 6 weeks or as needed.

**Improved on Vyvanse 20mg PO daily per parent and teacher report; no side effects.**
- Continue Vyvanse 20mg PO daily
- Reassess at next visit

Return to clinic in 3 months or as needed.

**Inadequate symptom control on Concerta 27mg PO daily per parent and teacher report.**
- Transition to Vyvanse 20mg PO daily
- Reassess response at one-month follow-up

Return to clinic in one month or as needed.

**Stable; BMI unchanged since last visit, currently on dietary counseling and activity plan.**
- Continue dietary counseling
- Encourage 60 min physical activity daily
- Recheck BMI at next visit

Return to clinic in 3 months or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning. Use numbered plan items instead of bullet points.

---

## Output Structure for Each Problem/Diagnosis

**[Month Year]**: [Write a one-liner (<20 words) in telegraphic clinical language that states the reason for the visit, the key management decision and its main clinical rationale.]

**[Problem/Diagnosis Name]**
1. [A very brief numbered item summarizing a key finding, action, or follow-up plan]
2. [Each point should be a separate numbered item, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after the numbered list when applicable. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. All questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

---

## Formatting Rules

1. Bold formatting for problem names and Month Year
2. Italicized formatting for all boilerplate text
3. Do NOT use section headers like Assessment or Plan
4. Use sequential numbers (1. 2. 3.) for all plan items — not hyphens or bullets
5. Restart numbering at 1 for each new problem
6. Write all items in extremely brief, professional shorthand phrases
7. Keep items concise (ideally under 10 words per item)
8. Use standard medical abbreviations (RTC, PRN, BID, etc.)
9. Never fabricate or infer information not present in the source text
10. Insert a blank line between problems when multiple diagnoses exist
11. No references

---

## Few-Shot Examples

Patient presents with acute asthma exacerbation; plan to start ICS given persistent symptoms despite albuterol.

**Asthma**
1. Flovent 44mcg 2 puff BID started
2. Continue albuterol PRN
3. Use spacer

Return to clinic in 3 months or as needed.

Patient presents for well child check; normal growth/development, no concerns identified.

**Well Child Check**
1. Growing and developing well
2. Reviewed anticipatory guidance

Return to clinic at next well child check or as needed.

Patient presents with vomiting and mild dehydration; giving Zofran and oral rehydration given tolerating small sips.

**Vomiting, mild dehydration**
1. NDNT on exam with MMM
2. Zofran PRN, pedialyte, Tylenol, Motrin

Return to clinic as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write a single concise blurb in the style of a well-trained resident's oral presentation: state the key findings and clinical assessment, the treatment plan, and any forward-directed thinking such as return precautions, contingency plans, or follow-up expectations. The blurb may be one sentence or a few short sentences, but must remain as brief as possible without losing essential clinical meaning.

---

## Output Structure For Each Problem/Diagnosis

**[Problem/Diagnosis Name]**
[Resident-style blurb: assessment + plan + forward-directed thinking.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem blurbs and before the follow-up line when applicable. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. All questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

---

## Formatting Rules

1. **Bold formatting** for problem names
2. **Italicized formatting** for all boilerplate text
3. Write the problem/diagnosis name followed by the blurb written below on a new line
4. Write the blurb as flowing prose — no bullet points
5. Keep each blurb as concise as possible; length should match complexity of the problem
6. Use standard medical abbreviations (BID, etc.)
7. Include forward-directed thinking (return precautions, contingency plans, follow-up expectations) within the blurb itself where naturally applicable
8. Only include the follow-up statement once, at the end
9. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

**Asthma**
Persistent symptoms despite albuterol consistent with inadequately controlled asthma; starting Flovent 44mcg 2 puffs BID with spacer, continue albuterol as needed, and will reassess control at follow-up.

Return to clinic in 3 months or as needed.

**Well Child Check**
Healthy 4yo with normal growth, development, and exam; all anticipatory guidance reviewed, vaccines UTD, no concerns identified.

Return to clinic at next well child check or as needed.

**Vomiting, mild dehydration**
Tolerating small sips with moist mucous membranes and non-distended abdomen on exam, consistent with mild dehydration without need for IV fluids at this time; Zofran and oral rehydration with Pedialyte recommended, with Tylenol/Motrin as needed, and family instructed to go to ED if unable to maintain hydration.

Return to clinic as needed.

**ADHD**
Inadequate symptom control on Concerta 27mg per parent and teacher report; transitioning to Vyvanse 20mg PO daily and will reassess response at one-month follow-up.

Return to clinic in one month or as needed.

**Viral URI**
Presentation consistent with viral upper respiratory infection; supportive care with fluids and OTC medications recommended, family declined COVID testing, return precautions reviewed.

Return to clinic as needed.

Reformat the assessment and plan into a system-based format. Organize the output by organ system rather than by individual problem or diagnosis. Cover all of the following systems in every note in this exact order: Respiratory, Cardiovascular, FEN/GI, ID, HO, Neuro, Psych, Social, Dispo. For systems that are stable or not clinically relevant, write a simple one-line negative statement. For systems with active issues, write a brief assessment followed by concise bulleted plan items.

Begin with a brief summary statement (<2 sentences) stating the patient identifier, the primary reason for admission or visit, and hospital day if applicable.

---

## Output Structure

**[Patient Identifier, Primary Reason for Admission/Visit, HD#]**

**Respiratory**: [Assessment and plan, or simple negative statement]
**Cardiovascular**: [Assessment and plan, or simple negative statement]
**FEN/GI**: [Assessment and plan, or simple negative statement]
**ID**: [Assessment and plan, or simple negative statement]
**HO**: [Assessment and plan, or simple negative statement]
**Neuro**: [Assessment and plan, or simple negative statement]
**Psych**: [Assessment and plan, or simple negative statement]
**Social**: [Assessment and plan, or simple negative statement]
**Dispo**: [Assessment and plan, or simple negative statement]

---

## Formatting Rules

1. **Bold formatting** for the organ system names
2. Always include all 9 systems in the order listed above, even if stable
3. For stable/non-relevant systems, write one brief negative statement on the same line (e.g., "**Respiratory**: Stable on room air")
4. For active systems, put the assessment/plan on a new line or same line concisely
5. Use a hyphen (-) for all bulleted plan items
6. Write all bullet points in extremely brief, professional shorthand phrases
7. Keep bullets concise (ideally under 10 words per bullet)
8. Use standard medical abbreviations (BID, PRN, PO, IV, etc.)
9. The summary statement should be telegraphic and concise
10. Never fabricate or infer information not present in the source text
11. No references

---

## Few-Shot Examples

**8yo admitted for acute asthma exacerbation with hypoxia requiring supplemental O2; HD#2.**

**Respiratory**: Asthma exacerbation, improved on continuous albuterol, now spacing to q4h; weaning O2.
- Albuterol neb q4h
- Wean O2 to maintain SpO2 >92%
- Start Flovent 44mcg 2 puffs BID once spacing to q6h
- Continue monitoring respiratory status

**Cardiovascular**: Hemodynamically stable, no concerns.

**FEN/GI**: Tolerating regular diet, adequate PO intake.

**ID**: Afebrile, no signs of infection.

**HO**: No hematologic or oncologic concerns.

**Neuro**: Alert, age-appropriate, no focal deficits.

**Psych**: Appropriate affect, coping well with hospitalization.

**Social**: Parents at bedside, family meeting completed. School notified of absence.

**Dispo**: Likely discharge tomorrow if tolerating albuterol q6h on room air.
- Discharge with Flovent 44mcg 2 puffs BID, albuterol PRN
- Asthma action plan to family
- Follow-up with PCP in 1 week

**65yo presenting with fever, cough, and hypoxia; CXR with RLL consolidation consistent with community-acquired pneumonia.**

**Respiratory**: Right lower lobe pneumonia on CXR; requiring 2L NC to maintain SpO2 >94%.
- Supplemental O2 2L NC
- Chest PT and incentive spirometry
- Monitor respiratory status for clinical deterioration

**Cardiovascular**: Sinus tachycardia, likely demand; no acute cardiac concerns.

**FEN/GI**: Mild dehydration on presentation; tolerating sips.
- NS bolus 1L, then D5 1/2NS at 100mL/hr
- Advance diet as tolerated

**ID**: Febrile to 39.1C; WBC 15.2 with left shift. Blood cultures drawn.
- Ceftriaxone 1g IV daily + azithromycin 500mg IV daily
- Monitor fever curve and WBC trend
- Follow blood cultures

**HO**: No hematologic or oncologic concerns.

**Neuro**: Alert and oriented x4, no focal deficits.

**Psych**: Anxious about hospitalization; reassurance provided.

**Social**: Lives alone; daughter is emergency contact and updated. Will need to assess home safety prior to discharge.

**Dispo**: Admit to medicine for IV antibiotics and O2 monitoring.
- Anticipated 2-3 day stay
- Transition to PO antibiotics when afebrile x24h and tolerating PO
- Follow-up with PCP within 1 week of discharge

Reformat the assessment and plan into the most concise format possible. For each problem, write exactly one telegraphic sentence that fuses the assessment and plan together: state the key clinical finding or interpretation, then the action taken, separated by a semicolon. No bullets, no subsections, no headers beyond the problem name. Each problem gets only one line.

---

## Output Structure For Each Problem/Diagnosis

**[Problem/Diagnosis Name]**
[Single sentence: key finding/assessment; action taken/plan.]

[Follow-Up: Brief description of follow-up plan if discussed.]

---

## Conditional Boilerplate Text

[Insert after all problem lines and before the follow-up line when applicable. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. All questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

---

## Formatting Rules

1. **Bold formatting** for problem names
2. **Italicized formatting** for boilerplate text
3. Do NOT use section headers like Assessment or Plan
4. Exactly one sentence per problem — no more
5. Use a semicolon to separate assessment from plan within the sentence
6. Write in telegraphic clinical shorthand — omit articles and filler words
7. Use standard medical abbreviations (PRN, BID, PO, RTC, etc.)
8. Keep each sentence as short as possible; aim for under 25 words
9. No bullets, no numbered lists, no subsections
10. Insert a blank line between each problem
11. Only include the follow-up statement once, at the end
12. If follow-up was not explicitly discussed, default to "Return to clinic as needed"

---

## Few-Shot Examples

**Asthma**
Persistent symptoms despite albuterol; starting Flovent 44mcg 2 puffs BID with spacer.

Return to clinic in 3 months or PRN.

**Well Child Check**
Healthy 4yo, normal growth and development; anticipatory guidance reviewed, vaccines UTD.

Return to clinic at next well child check or PRN.

**Vomiting, mild dehydration**
Tolerating sips, MMM, NDNT; Zofran PRN and oral rehydration with Pedialyte.

Return to clinic PRN.

**ADHD**
Inadequate control on Concerta 27mg per parent/teacher report; transitioning to Vyvanse 20mg PO daily.

Return to clinic in 1mo.

**Viral URI**
Symptoms consistent with viral URI, no red flags; supportive care with fluids, family declined COVID test.

Return to clinic PRN.

Reformat the assessment and plan into a structured, problem-oriented format with clear visual hierarchy.

-----

## Output Structure for Each Problem/Diagnosis

**[Problem/Diagnosis Name]**

Assessment:
    · [Bullet points summarizing diagnostic reasoning and clinical context using formal medical terminology]
    · [Use "reassuring" rather than "normal" when appropriate]
    · [Avoid speculation beyond stated clinical findings]

Plan:
    · [Immediate interventions, medications, procedures, and orders]
    · [Each action item as separate bullet]

Next Steps:
    · [Conditional planning with scenario-based language: "If [symptom/test], then [action]"]
    · [Follow-up intervals and return precautions]
    · [Monitoring parameters]

-----

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

-----

## Formatting Rules

1. **Bold formatting** for problem names and **Italicized formatting** for section headers and boilerplate text
2. **Indent** section headers (Assessment, Plan, Next Steps) with 4 spaces
3. **Indent bullets** under each section with 8 spaces
4. Write all content in clear, short, professional phrases
5. Include only sections actually discussed; omit unused sections entirely
6. Never fabricate or infer information not present in the source text
7. No abbreviations except standard medical ones (BID, mcg, etc.)
8. Keep bullets concise (ideally under 15 words per bullet)
9. Insert blank line between problems when multiple diagnoses exist
10. No references

-----

## Few-Shot Examples

**Asthma**

Assessment:
    · Child with history of mild persistent asthma.
    · Recent exacerbation requiring albuterol use multiple times per week.
    · Exam reassuring with clear breath sounds today.

Plan:
    · Start Flovent 44 mcg, 2 puffs BID with spacer.
    · Continue albuterol inhaler as rescue.
    · Provide asthma action plan to family.

Next Steps:
    · Follow up in 3 months for asthma control check.
    · Return sooner for increased rescue use, nighttime symptoms, or respiratory distress.
    · If control remains poor, consider montelukast or referral to Allergy.

-----

**ADHD**

Assessment:
    · Ongoing ADHD with good response to stimulant therapy.
    · Parent reports new mood instability since starting Adderall XR.
    · Growth and vitals reassuring today.

Plan:
    · Discontinue Adderall XR.
    · Start trial of Concerta.
    · Provide teacher Vanderbilt forms for monitoring.

Next Steps:
    · Follow up in 1 month for medication response.
    · Return sooner for significant appetite suppression, sleep disturbance, or mood changes.

-----

**Eczema**

Assessment:
    · Atopic dermatitis with mild flare on flexural surfaces.
    · Skin exam otherwise reassuring.

Plan:
    · Start triamcinolone 0.1% ointment BID for 2 weeks.
    · Continue daily emollient use.

Next Steps:
    · Follow up in 3 months, sooner if rash worsens or new infection develops.

-----

## Additional Guidance for Complex Cases

**When multiple related problems exist** (e.g., "Upper Respiratory Infection" and "Acute Otitis Media"):

- Keep as separate problem headers for billing support
- Avoid redundant boilerplate; include once at end if applicable to both

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning.

---

## Output Structure for Each Problem/Diagnosis

**[Problem/Diagnosis Name]**
- [A very brief bullet point summarizing a key finding, action, or follow-up plan]
- [Each point should be a separate bullet, written as a short clinical shorthand phrase]

---

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable. This text should be italicized.]

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

If ear infection discussed:
"Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis."

If strep test discussed:
"Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management."

If dehydration, vomiting, diarrhea, or decreased urination discussed:
"Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids."

If trouble breathing discussed:
"Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission."

If ADHD, obesity, or strep throat discussed:
"PCMH Reminder"

---

## Formatting Rules

1. Bold formatting for problem names
2. Italicized formatting for all boilerplate text
3. Do NOT use section headers like Assessment or Plan
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Write all bullet points in extremely brief, professional shorthand phrases
7. Keep bullets concise (ideally under 10 words per bullet)
8. Use standard medical abbreviations (RTC, PRN, BID, etc.)
9. Never fabricate or infer information not present in the source text
10. Insert a blank line between problems when multiple diagnoses exist
11. No references

---

## Few-Shot Examples

**Asthma**
- Flovent 44mcg 2 puff BID started
- Continue albuterol PRN
- Use spacer
- RTC 3mo/PRN

**Well Child Check**
- Growing and developing well
- Reviewed anticipatory guidance
- RTC 1yr/PRN

**Vomiting, mild dehydration**
- NDNT on exam with MMM
- Zofran PRN, pedialyte, Tylenol, Motrin
- RTC PRN

**ADHD**
- Concerta 27mg not effective
- Transition to Vyvanse 20mg PO daily
- RTC 1mo

**Viral URI**
- Supportive care, fluids
- Declined COVID test
- RTC PRN

Sign-Off & Family To-Do Generator
Generate two components: 3 personalized sign-off options and a family to-do list.

PART 1: PERSONALIZED SIGN-OFFS
Create 3 brief, warm sign-off options matching visit context.
Structure: [Personal touch/acknowledgment], [well-wish or next step]. [Closing]
Guidelines:
·	Warm and genuine, never formulaic
·	Acknowledge something specific when possible
·	Match emotional tone to visit type
·	Keep <=25 words total
·	Balance professional with personable
·	Reference activities, interests, milestones if mentioned
·	For difficult visits: acknowledge courage, effort, or partnership
Visit-Specific Approaches:
Well visits/milestones: Celebrate growth, reference developmental milestones Sick visits: Empathize, offer comfort suggestion, reassure about calling Chronic conditions: Acknowledge effort, emphasize partnership Behavioral/mental health: Acknowledge courage, normalize seeking help Complex/concerning: Name plan clearly, offer availability Referrals: Acknowledge next step, reassure continuity
Examples:
5yo female well visit, starting kindergarten, plays soccer:
Great seeing y'all today! Good luck with soccer and kindergarten! Excited for you!
She is going to do great in kindergarten. Can't wait to hear about it next visit!
What an exciting year ahead! We're here if you need anything.
Male, Viral laryngitis, strep pending, difficult hydrating:
Drink lots of fluids! Popsicles are my favorite when sick. Call if not improving.
Hope he feels better soon. Those popsicles should help. We'll call with results tomorrow.
It is hard when they feel so crummy. Keep offering fluids and call if he's not gettting better. We're here!
Female, New ADHD diagnosis, parent emotional, starting medication:
It takes courage to have this conversation-thank you for advocating for her! We're here to support you.
You're doing the right thing getting her help. We'll partner with you every step. Call anytime.
A new diagnosis can feel overwhelming, but we'll take it step by step. We're here for you.
Male, Asthma exacerbation, previous PICU admission, pulmonology referral:
We'll get him to Pulmonology to help get on top of all of this. Call if anything changes-we're here.
It is scary navigating all of this after your experiences. The specialist will help us care for him. Please call with any concerns.
You're doing everything right seeking care early. Don't hesitate to reach out.
Key Elements to Extract: Patient name, activities/hobbies, school transitions, specific treatments, emotional tone, referrals, chronic conditions, parent effort, family context
Output: 
{Personalized sign off specific to visit}
{Personalizes sign off emphasizing relationship}
{Personalized sign off forward-looking/supportive}

PART 2: FAMILY TO-DO LIST
Extract actionable items into simple checklist. Include only concrete next steps with essential details.
Format:
Your To-Do List:
Prescriptions:
·	[If none: omit "No new prescriptions today."]
Tests/Results:
·	[Test]: Results pending, we will call [timeframe] [If none: omit section]
Appointments:
·	Schedule [specialty] appointment
·	Return to clinic in [timeframe] [If none: "No appointments to schedule today."]

Rules:
1.	Simple dashes for bullets
2.	One item per line, <=12 words
3.	Only items requiring family action
4.	Be specific about timeframes
5.	Bold section headers
6.	No explanations, just actions
7.	Extract from note only
8.  Indent all bullets with 8 spaces followed by simple dash
Examples:
Viral laryngitis, strep pending, acetaminophen, follow up 7 days if no improvement:
Your To-Do List:
Tests/Results:
·	Strep test: Results pending, we will call tomorrow
Appointments:
·	Return to clinic if no improvement in 7 days
Asthma exacerbation, Flovent and albuterol started, pulmonology referral, 3-month follow-up:
Your To-Do List:
Prescriptions:
·	Flovent with spacer
·	Albuterol inhaler as needed for wheezing/coughing
Appointments:
·	Schedule Pulmonology appointment
·	Return to clinic in 3 months for asthma check
Include: All new/changed prescriptions, pending test results, referrals needing scheduling, specific return timeframes, concrete action items
Exclude: General advice (fluids, rest), warning signs, explanations, background info

COMPLETE OUTPUT
{Personalized sign off specific to visit}
{Personalizes sign off emphasizing relationship}
{Personalized sign off forward-looking/supportive}

To-Do List:
Prescriptions: [list or "No new prescriptions today."]
Tests/Results: [list or omit if none]
Appointments: [list or "No appointments to schedule today."]

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning.

---

## Output Structure for Each Problem/Diagnosis

**[Month Year]**:[Brief summary statement stating reason for visit in form of “Patient presents…” along with brief summary of plan]

**[Problem/Diagnosis Name]**
- [A very brief bullet point summarizing a key finding, action, or follow-up plan]
- [Each point should be a separate bullet, written as a short clinical shorthand phrase]

[Follow-Up: Brief description of follow up plan if discussed]

---

## Conditional Boilerplate Text

[Insert after the bulleted list when applicable. This text should be italicized.]

If trigger discussed:
"Your dot phrase here.  You may need to experiment some with different trigger words that will fire consistently for you but terms you know you say in the room or ICD-10 codes are both good places to start. Remember there is a balance to the convenience of automatically including your favorite dot phrases vs giving the model a wall of essentially unrelated text that it parses for instructions degrading performance.  Start with your top 3-5 and then include more if desired after testing."

If well child check or health maintenance discussed:
"All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. All questions addressed."

If any illness discussed:
"Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan."

If any injury discussed:
"Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve."

---

## Formatting Rules

1. Bold formatting for problem names and Month Year
2. Italicized formatting for all boilerplate text
3. Do NOT use section headers like Assessment or Plan
4. Use a hyphen (-) for all bullets
5. Indent all bullets with 8 spaces
6. Write all bullet points in extremely brief, professional shorthand phrases
7. Keep bullets concise (ideally under 10 words per bullet)
8. Use standard medical abbreviations (RTC, PRN, BID, etc.)
9. Never fabricate or infer information not present in the source text
10. Insert a blank line between problems when multiple diagnoses exist
11. No references

---

## Few-Shot Examples

Patient presents with acute asthma exacerbation; plan to start Flovent.

**Asthma**
- Flovent 44mcg 2 puff BID started
- Continue albuterol PRN
- Use spacer

Return to clinic in 3 months or as needed.

Patient presents for well child check; growing and developing well.

**Well Child Check**
- Growing and developing well
- Reviewed anticipatory guidance

Return to clinic at next well child check or as needed.

Patient presents with vomiting and dehydration; plan to give supportive care with pedialyte and zofran.

**Vomiting, mild dehydration**
- NDNT on exam with MMM
- Zofran PRN, pedialyte, Tylenol, Motrin

Return to clinic as needed.

Patient presents for ongoing management of ADHD; plan to transition from Concerta to Vyvanse.

**ADHD**
- Concerta 27mg not effective
- Transition to Vyvanse 20mg PO daily
- RTC 1mo

Return to clinic on one month.

Patient presents with upper respiratory symptoms; plan to give supportive care with emphasis on hydration.

**Viral URI**
- Supportive care, fluids
- Declined COVID test

Return to clinic as needed.

Convert this clinical note into a concise study guide designed to prepare a student to be quizzed on topics related to this case.

Output Structure
CASE PRESENTATION [Rewrite the case in standard presentation format: Demographics (age/gender only), Chief Complaint, HPI, Pertinent Physical Exam, Assessment and Plan]
LEARNING OBJECTIVES
1.	[Specific, measurable objective related to diagnosis]
2.	[Specific, measurable objective related to management]
3.	[Specific, measurable objective related to clinical reasoning]
DISCUSSION QUESTIONS
1.	[Open-ended question about differential diagnosis]
	- Answer
2.	[Question about diagnostic approach or testing]
	- Answer
3.	[Question about management decisions]
	- Answer
4.	[Question about when to escalate or refer]
	- Answer
KEY TEACHING POINTS
·	[Clinical pearl #1]
·	[Clinical pearl #2]
·	[Clinical pearl #3]

Few-Shot Examples
Input: 5yo male, fever 102.5 x 2 days, sore throat, + strep test, started amoxicillin
Output:
CASE PRESENTATION A preschool-age male presented with 2 days of fever (max 102.5°F) and sore throat. Physical exam revealed tonsillar exudates and anterior cervical lymphadenopathy. Rapid strep test was positive. The patient was started on amoxicillin 50mg/kg/day divided BID for 10 days.
LEARNING OBJECTIVES
1.	Apply Centor criteria to determine when strep testing is indicated in pediatric pharyngitis
2.	Prescribe appropriate antibiotic therapy for group A streptococcal pharyngitis
3.	Counsel families on complications of untreated strep throat
DISCUSSION QUESTIONS
1.	What clinical features increase the likelihood of bacterial vs viral pharyngitis in children?
	- Exudate on exam and lack of coughing
2.	When is empiric antibiotic therapy appropriate without testing?
	- Amoxicillin is first line
3.	How would management change if the patient had a penicillin allergy?
	- Keflex if not anaphylactic, azithromycin if it was anaphylactic
4.	What are the potential complications of untreated streptococcal pharyngitis?
	- Rhuematic fever is the major concern, also Post-streptococcal glomerulonephritis (PSGN) is the one that treatment doesn't change the risk 
KEY TEACHING POINTS
·	Centor criteria have limited utility in children under age 3
·	Amoxicillin remains first-line therapy due to narrow spectrum and efficacy
·	Symptoms improve within 48-72 hours but full 10-day course prevents complications

Input: 16yo female with worsening asthma, using albuterol 5-6x/day, nighttime cough, exam with mild expiratory wheeze, not on controller, started Flovent 88mcg BID
Output:
CASE PRESENTATION An adolescent female with known asthma presented with worsening symptoms over the past 2 weeks. She reported using her albuterol rescue inhaler 5-6 times daily and experiencing nighttime cough 3-4 times per week. She was not on controller medication. Physical exam revealed mild expiratory wheezing bilaterally. She was started on fluticasone 88mcg 2 puffs twice daily with spacer and counseled on proper inhaler technique.
LEARNING OBJECTIVES
1.	Classify asthma severity using NHLBI guidelines
2.	Recognize indications for initiating controller therapy in asthma
3.	Prescribe appropriate step therapy for persistent asthma
DISCUSSION QUESTIONS
1.	How do you differentiate mild intermittent from mild persistent asthma?
- For mild persistent asthma symptoms occur more than twice a week but less than once a day; Nighttime symptoms more than twice a month but less than once a week
2.	What factors indicate the need for controller medication vs rescue therapy alone?
	- Number and severity of exacerbations
3.	What would prompt escalation to Step 3 or 4 therapy?
	- Number and severity of exacerbations
4.	How would you counsel this patient on proper inhaler technique and adherence?
	- Using a spacer is key
KEY TEACHING POINTS
·	Rescue inhaler use >2 days/week indicates inadequate control and need for controller
·	Nighttime symptoms are a key marker of persistent asthma
·	Spacers improve medication delivery and reduce oral thrush risk with ICS

Quality Checks
Before outputting, verify: 1. Clinical accuracy preserved 2. 3 learning objectives that are specific and measurable 3. 4 discussion questions that promote critical thinking with answers  4. teaching points that are concise and actionable 5. Case written in standard presentation format

Convert this clinical note into a structured teaching case. Remove all identifying information and create educational content suitable for medical students or residents.

Output Structure
CASE PRESENTATION [Rewrite the case in standard presentation format: Demographics (age/gender only), Chief Complaint, HPI, Pertinent Physical Exam, Assessment and Plan]
LEARNING OBJECTIVES
1.	[Specific, measurable objective related to diagnosis]
2.	[Specific, measurable objective related to management]
3.	[Specific, measurable objective related to clinical reasoning]
DISCUSSION QUESTIONS
1.	[Open-ended question about differential diagnosis]
2.	[Question about diagnostic approach or testing]
3.	[Question about management decisions]
4.	[Question about when to escalate or refer]
KEY TEACHING POINTS
·	[Clinical pearl #1]
·	[Clinical pearl #2]
·	[Clinical pearl #3]

De-identification Rules
1.	Replace specific ages with age ranges (e.g., "7-year-old" becomes "school-age child")
2.	Remove all names, use "the patient" or "the child"
3.	Remove specific dates, use relative timeframes ("presented 3 days after symptom onset")
4.	Keep clinical details intact - diagnosis, symptoms, exam findings, management
5.	Preserve medication names, doses, and clinical decision-making

Few-Shot Examples
Input: 5yo male, fever 102.5 x 2 days, sore throat, + strep test, started amoxicillin
Output:
CASE PRESENTATION A preschool-age male presented with 2 days of fever (max 102.5°F) and sore throat. Physical exam revealed tonsillar exudates and anterior cervical lymphadenopathy. Rapid strep test was positive. The patient was started on amoxicillin 50mg/kg/day divided BID for 10 days.
LEARNING OBJECTIVES
1.	Apply Centor criteria to determine when strep testing is indicated in pediatric pharyngitis
2.	Prescribe appropriate antibiotic therapy for group A streptococcal pharyngitis
3.	Counsel families on complications of untreated strep throat
DISCUSSION QUESTIONS
1.	What clinical features increase the likelihood of bacterial vs viral pharyngitis in children?
2.	When is empiric antibiotic therapy appropriate without testing?
3.	How would management change if the patient had a penicillin allergy?
4.	What are the potential complications of untreated streptococcal pharyngitis?
KEY TEACHING POINTS
·	Centor criteria have limited utility in children under age 3
·	Amoxicillin remains first-line therapy due to narrow spectrum and efficacy
·	Symptoms improve within 48-72 hours but full 10-day course prevents complications

Input: 16yo female with worsening asthma, using albuterol 5-6x/day, nighttime cough, exam with mild expiratory wheeze, not on controller, started Flovent 88mcg BID
Output:
CASE PRESENTATION An adolescent female with known asthma presented with worsening symptoms over the past 2 weeks. She reported using her albuterol rescue inhaler 5-6 times daily and experiencing nighttime cough 3-4 times per week. She was not on controller medication. Physical exam revealed mild expiratory wheezing bilaterally. She was started on fluticasone 88mcg 2 puffs twice daily with spacer and counseled on proper inhaler technique.
LEARNING OBJECTIVES
1.	Classify asthma severity using NHLBI guidelines
2.	Recognize indications for initiating controller therapy in asthma
3.	Prescribe appropriate step therapy for persistent asthma
DISCUSSION QUESTIONS
1.	How do you differentiate mild intermittent from mild persistent asthma?
2.	What factors indicate the need for controller medication vs rescue therapy alone?
3.	What would prompt escalation to Step 3 or 4 therapy?
4.	How would you counsel this patient on proper inhaler technique and adherence?
KEY TEACHING POINTS
·	Rescue inhaler use >2 days/week indicates inadequate control and need for controller
·	Nighttime symptoms are a key marker of persistent asthma
·	Spacers improve medication delivery and reduce oral thrush risk with ICS

Quality Checks
Before outputting, verify: 1. All identifying information removed 2. Clinical accuracy preserved 3. 3 learning objectives that are specific and measurable 4. 4 discussion questions that promote critical thinking  5. teaching points that are concise and actionable 6. Case written in standard presentation format

One-Minute Preceptor Teaching Feedback Prompt
Purpose
Generate three targeted teaching questions based on the Assessment & Plan, using the One-Minute Preceptor microskills framework to provide in-the-moment feedback.

Prompt
You are an experienced clinical educator providing real-time feedback using the One-Minute Preceptor method. Your task is to generate three focused teaching questions based on the Assessment & Plan given to you.

Generate Three Teaching Questions
1. Probe for Evidence (Microskill 2)
Your task: Examine the A&P and identify the specific clinical data that led to the diagnosis or management decision. Look for exam findings, lab values, imaging results, or history elements mentioned. Then craft a question that asks the clinician to articulate how those elements played into their reasoning.
Question structure: Reference the specific findings from the A&P and ask the clinician to explain their reasoning process-how these findings informed their diagnostic or management decisions.
Example pattern: In this patient with [actual diagnosis from A&P], how did [specific finding mentioned] and [another specific finding mentioned] influence your decision to [actual decision made]?
Alternative pattern: Walk me through your reasoning: what aspects of [specific findings from A&P] made you most confident in [diagnosis/management decision]?
Output your question:

2. Reflect on the Decision (Microskill 4)
Your task: Identify a decision point in the A&P where the clinician made a choice-this could be ordering or NOT ordering a test, starting or withholding treatment, pursuing or deferring imaging, consulting or managing independently, choosing observation over intervention, etc. Frame a question that invites reflection on that decision without implying the decision was wrong.
Question structure: Identify the specific decision made (action taken OR action not taken) and ask what factors influenced that choice, or what would change their approach.
Example patterns:
·	What factors led you to [actual decision made/not made] in this case?
·	How did you decide between [option chosen] and [alternative approach] for this patient?
·	What would have changed your threshold for [ordering test/starting treatment/consulting] in this scenario?
·	If [specific variable] had been different, would that have changed your decision to [actual choice made]?
Output your question:

3. Extract the Clinical Pearl (Microskill 5)
Your task: Identify one generalizable clinical principle from this case that extends beyond this specific patient. This could be a decision-making framework, a diagnostic approach, a management principle, or practical clinical wisdom. State it concisely (<=20 words).
Format: State the pearl as a single sentence that captures the generalizable principle.
Example: Empiric antibiotics in clinically evident pneumonia reduce morbidity even before imaging confirmation.
Output your pearl:

Example
A&P Input: 38-year-old with fever, cough × 3 days. Exam: temperature 38.5°C, left basilar crackles, no tachycardia. CXR pending. Diagnosis: Community-acquired pneumonia. Plan: Azithromycin 500mg × 1, amoxicillin-clavulanate × 7 days, supportive care, recheck in 48 hours.
Generated Questions:
Question 1 - Probe for Evidence: Walk me through your reasoning: how did the combination of left basilar crackles, fever to 38.5°C, and the 3-day history of productive cough lead you to start antibiotics before the CXR returned?
Question 2 - Reflect on the Decision: What factors influenced your decision to start empiric antibiotics before getting the chest X-ray, rather than waiting for imaging confirmation?
Alternative Question 2 example (if labs were NOT ordered): How did you decide that labs weren't necessary in this case-what aspects of the presentation made you comfortable proceeding without a CBC or inflammatory markers?
Question 3 - Extract the Clinical Pearl: Clinical certainty from exam findings and history can justify empiric pneumonia treatment before imaging.

Quality Check
Each generated question should:
·	Reference specific content from the A&P (diagnoses, findings, medications, decisions)
·	Be conversational and respectful, not interrogatory
·	Invite reflection on reasoning, not imply right or wrong
·	Focus on decision-making process, not knowledge recall
·	Be neutral about whether action or inaction was the better choice

From this case, extract one brief 'Clinical Pearl' for teaching (<=20 words). Focus on a practical pitfall, tip, or insight-not patient-specific.
Using that clinical pearl, then take it one step farther and ask the clinician a socratic style follow up question to cause them to think more deeply about this particular patient. Write each on a separate line below bolded header "Clinical Pearl:"

Analyze this note and determine the appropriate CPT E/M billing code using 2021 E/M guidelines for an ESTABLISHED patient.
MDM Component Assessment
A. PROBLEMS ADDRESSED
·   Straightforward: 1 self-limited/minor problem
·   Low: 2+ self-limited/minor problems OR 1 stable chronic illness OR 1 acute uncomplicated illness
·   Moderate: Chronic illness with exacerbation/progression OR 2+ stable chronic illnesses OR undiagnosed new problem OR acute illness with systemic symptoms OR acute complicated injury
·   High: Chronic illness with severe exacerbation OR illness posing threat to life/bodily function
B. DATA COMPLEXITY
·   Low: Assessment requires independent historian, None or one piece of data reviewed/ordered along with 
·   Moderate: Any combination of two tests ordered, test results reviewed, or prior external notes reviewed along with assessment requiring an independent historian
·   High: Meets criteria for Moderate AND discussion with external physician regarding interpretation of tests OR independent test interpretation
C. RISK LEVEL
·   Minimal: Minimal risk from testing/treatment
·   Low: OTC medications, rest, observation
·   Moderate: Prescription drugs, Dx or Rx limited by social factors
·   High: Decision regarding hospitalization
2-of-3 Rule
Overall MDM = level met by at least 2 of 3 components.
·   Straightforward = 99212
·   Low = 99213
·   Moderate = 99214
·   High = 99215
Modifier 25 Check
Add modifier 25 for a separately identifiable E/M service during a Well Child Check/Routine child health examination. 
Output Format
Problems: [Level] [Brief explanation]
Data: [Level] [What was reviewed/ordered]
Risk: [Level] [Treatment risk level and why]
MDM Score: Problems ([Level]) + Data ([Level]) + Risk ([Level]) = [Overall Level] (based on 2 of 3)
Final Code: 99XXX
Modifier 25 Format:
Modifier 25: Well visit with separate E/M for:
 - [Problem 1] ([brief intervention])
 - [Problem 2] ([brief intervention])
Critical Coding Rules
1. Ordering any culture (e.g., strep, urine) implies consideration of prescription management and elevates Risk to at least Moderate.
2. Acute illness with systemic symptoms + any culture ordered = 99214 (Moderate Problems + Moderate Data + Moderate Risk).
3. Assume Assessment requiring an independent historian is always true.
Examples
Viral URI (simple) Runny nose, cough. Exam: clear. Plan: supportive care.
Problems: Low (1 acute uncomplicated) Data: Minimal Risk: Low (supportive care only) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Straightforward (based on 2 of 3) Final Code: 99212
Strep Throat Sore throat, fever 102F, body aches. Exam: exudates. Plan: strep test, amox if positive.
Problems: Moderate (Acute illness with systemic symptoms) Data: Moderate (test ordered) Risk: Moderate (prescription antibiotic) MDM Score: Problems (Moderate) + Data (Moderate) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
UTI with Fever Toddler with fever 102.5, crying with urination. Exam: suprapubic tenderness. Urine dipstick positive. Plan: send urine culture.
Problems: Moderate (acute illness with systemic symptoms) Data: Moderate (2 tests ordered and independent historian) Risk: Moderate (culture implies potential prescription) MDM Score: Problems (Moderate) + Data (Moderate) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
Well Visit + Ear Infection 5yo well child check. Parent reports ear pain, fever x2 days. Exam: acute otitis media. Plan: amoxicillin.
Problems: Low (1 acute uncomplicated) Data: Minimal Risk: Moderate (prescription) MDM Score: Problems (Low) + Data (Minimal) + Risk (Moderate) = Low (based on 2 of 3) Final Code: 99393 + 99213-25 Modifier 25: Well visit with separate E/M for: - Acute otitis media (amoxicillin)
Well Visit + Multiple Issues 18-month well child check. Also has URI and diaper rash. Exam: clear rhinorrhea, diaper dermatitis. Plan: supportive care for URI, barrier cream for rash.
Problems: Low (2 self-limited problems: URI, diaper rash) Data: Minimal Risk: Low (OTC/supportive care) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Low (based on 2 of 3) Final Code: 99392 + 99213-25 Modifier 25: Well visit with separate E/M for: - Viral URI (supportive care) - Diaper rash (barrier cream)
Asthma Exacerbation, using albuterol 4-5x/day, night cough. Exam: mild wheezing. Plan: increase Flovent.
Problems: Moderate (chronic with exacerbation) Data: Minimal Risk: Moderate (prescription adjustment) MDM Score: Problems (Moderate) + Data (Minimal) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
Multiple Minor Issues Viral URI, diaper rash, small bruise. Exam unremarkable. Plan: supportive care, barrier cream, observation.
Problems: Low (3 self-limited problems) Data: Minimal Risk: Low (OTC only) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Straightforward (based on 2 of 3) Final Code: 99212
*Do not list any references that were used*

Create a concise sign-out for covering providers focusing on patients who may require attention during your absence.

Output Format
PATIENTS FOR SIGN-OUT
Patient [#]: [Age range/gender], [Chief diagnosis] Illness severity: [Stable / Close monitoring needed / Concerning]What's pending: [Tests, callbacks, decisions] Call if: [Specific triggers for contacting covering provider] Background:[Minimal context - 1-2 sentences max]

Rules
1.	Triage by illness severity
2.	Be explicit about when covering provider should act
3.	Keep background minimal - just enough context
4.	Focus on actionable information

Few-Shot Examples
Input: Strep test pending, empiric amoxicillin started, mild illness, follow up PRN
Output:
PATIENTS FOR SIGN-OUT
Patient 1: School-age child, suspected strep pharyngitis Illness severity: Stable What's pending: Rapid strep test results (expected tomorrow AM) Call if: Test returns positive (confirm family aware patient should complete 10-day course). If negative, call family to stop amoxicillin. Background: Mild pharyngitis, no respiratory distress. Started empiric amoxicillin pending test result.

Input: Asthma exacerbation, albuterol not helping at home, started oral steroid, close follow up
Output:
PATIENTS FOR SIGN-OUT
Patient 1: School-age child, asthma exacerbation Illness severity: Close monitoring needed What's pending: Clinical response to oral prednisone, family to update us tonight or tomorrow AM Call if: Family calls reporting worsening work of breathing, persistent cough despite treatment, or refusing to eat/drink. If so, advise ED evaluation. Background:Inadequate response to albuterol at home. Started prednisone 1mg/kg x 5 days in office. Sent home with strict return precautions. Consider admission if deterioration.

Input: Fever 103, irritable toddler, possible early meningitis, LP considered but deferred, close 12-hour recheck arranged
Output:
PATIENTS FOR SIGN-OUT
Patient 1: Toddler, fever without source - CONCERNING Illness severity: Concerning - requires close monitoringWhat's pending: 12-hour recheck scheduled tomorrow AM Call if: Family calls tonight reporting worsening irritability, lethargy, rash, seizure, poor responsiveness, or persistent inconsolability. If so, send directly to ED for evaluation including LP. Background: High fever, some irritability but consolable in office. Neuro exam reassuring. Urine dip negative. LP discussed but deferred due to clinical improvement in office after Tylenol. Close safety net and recheck arranged.

Input: New Type 1 diabetes, A1c 12%, DKA ruled out, endocrine referral placed
Output:
PATIENTS FOR SIGN-OUT
Patient 1: School-age child, new Type 1 diabetes diagnosis Illness severity: Stable (DKA ruled out) What's pending:Endocrine urgent referral placed - awaiting callback from their office Call if: Endocrine office hasn't called family by tomorrow AM (patient needs urgent subspecialist involvement). If family calls with vomiting, confusion, or difficulty breathing, send to ED for DKA evaluation. Background: New T1DM diagnosis made today. Labs showed glucose 350, pH 7.36 (no DKA). Started on basal-bolus insulin regimen. Family trained on blood sugar checks. Urgent endocrine referral for ongoing management.

Quality Checks
1. Triaged by urgency 2. Clear escalation triggers 3. Minimal background (only what's needed) 4. Action-oriented 5. Covering provider can act independently

If antibiotics are prescribed, analyze the prescription and output the name, dose, route, and duration followed by a non-judgemental question respectfully asking the clinican if this is the best choice in light of a detail from the patient's history:
 
Few shot examples:
1. Amoxicillin prescribed for ear infection in 4 year old
Amoxicillin 90mg/kg PO BID for 10 days was prescribed for acute otitis media.  Is this duration optimal for a 4 year old without recent ear infections?
2. Keflex for cellulitis in 5 year old
Keflex 50mg/kg/day divided TID for 5 days was prescribed for cellulitis.  What factors would cause you to consider a different dose in this 5 year old?
3. Azithromycin for cat scratch disease in 8 year old
Azithromycin 500mg PO once daily for one day followed by 250mg PO daily for 4 days was prescribed for cat scratch disease.  Why is this agent superior than its alternatives?

From the note, extract counseling, anticipatory guidance, and care instructions. Rewrite them as EMR Dot Phrase Snippets: short, reusable, professional sentences without patient identifiers.

# A/P Prompt Refiner

You are an expert at optimizing LLM prompts for clinical documentation. Your task is to analyze gaps between current and desired output, then refine the prompt to close those gaps.

-----

## Your Input

The user will provide:

1. **Current prompt** - Their A/P formatting prompt
1. **Ideal output** - 2-5 examples of what they want
1. **Current output** - 2-5 examples of what they’re getting

-----

## Analysis Process

### Step 1: Gap Analysis

Compare current vs ideal output:

- **Formatting**: Bullets, typography, spacing, headers, indentation
- **Content**: Brevity, language style, abbreviations, detail level
- **Logic**: Boilerplate triggering, conditional rules, consistency
- **Structure**: Organization, grouping, element placement

### Step 2: Root Cause

For each gap, identify WHY:

- Missing instruction
- Unclear instruction
- Weak/wrong examples
- Conflicting rules
- Wrong specificity level

### Step 3: Fix Design

Determine solution:

- Add/clarify instructions
- Modify few-shot examples (most powerful fix)
- Reorder for emphasis
- Remove conflicts
- Adjust specificity

-----

## Output Format

### Part 1: Gap Summary

List top 3-5 gaps:

```
1. [Gap] - What's wrong: [issue] | Root cause: [why] | Impact: [effect]
2. [Next gap]
```

### Part 2: Fixes

For each gap:

```
**Fix #1: [Gap]**
Action: [What to change]
Location: [Where in prompt]
Rationale: [Why this works]
```

### Part 3: Refined Prompt

Complete updated prompt with [UPDATED] markers on changes. Stay ≤5,000 characters.

### Part 4: Testing

```
Priority tests:
1. [Scenario]
2. [Scenario]

Watch for: [Potential issues]
```

-----

## Key Principles

**Hierarchy of Elements:**

1. Few-shot examples (most powerful)
1. Explicit rules
1. Task description
1. Boilerplate

**Common Patterns:**

- Few-shot example mismatch from desired output → refine few shot examples
- Too verbose → Add brevity rules, shorter examples, word limits
- Inconsistent format → Strengthen examples, specific rules
- Missing abbreviations → Show in examples, list explicitly
- Wrong detail level → Adjust example granularity

**Strategy:**

- Change ONE thing at a time
- Preserve what works
- Examples > instructions when in doubt
- Keep ≤5,000 characters
- Plain text only

-----

## Quality Checks

Before output:
✓ All gaps addressed
✓ No contradictions
✓ Examples match instructions
✓ ≤5,000 characters
✓ Changes marked [UPDATED]
✓ Working elements preserved

-----

## Output Template

```
# Gap Analysis
[Top 3-5 gaps with root causes]

# Recommended Changes
[Specific fixes]

# Refined Prompt
[Complete updated prompt with [UPDATED] markers]

# Character Count
Original: [X] / 5,000
Refined: [Y] / 5,000

# Testing
Priority tests: [scenarios]
Watch for: [issues]

# Changes Summary
[Quick bullet list]
```

# Custom A/P Formatting Prompt Generator

You are an expert at analyzing clinical documentation patterns and creating LLM prompts. Your task is to create a custom A/P formatting prompt based on the user’s examples and preferences.

-----

## Your Input Requirements

The user will provide:

1. **Few-shot examples** - 3-5 examples of their ideal A/P output (these are CRITICAL)
1. **Explicit formatting rules** (optional) - Any specific requirements they know they want
1. **Boilerplate phrases** (optional) - Standard text for common scenarios (illness, injury, well visits, etc.)

-----

## Your Analysis Process

### Step 1: Pattern Recognition

Analyze the few-shot examples for:

- **Formatting style**: Bullets vs prose, headers vs no headers, indentation patterns
- **Brevity level**: Detailed vs concise, word count per element
- **Organization**: Problem-oriented vs chronological, grouping patterns
- **Language style**: Clinical shorthand vs full sentences, abbreviation usage
- **Structural elements**: Spacing, separators, hierarchies

### Step 2: Extract Implicit Rules

Identify patterns the user may not have explicitly stated:

- Consistent abbreviations (RTC, PRN, BID, PO, etc.)
- Formatting conventions (bold, italics, capitalization)
- One-liner assessment if applicable
- Problem naming conventions
- Follow-up instruction patterns
- Medication notation style
- Conditional logic (when to include certain elements)

### Step 3: Synthesize Requirements

Combine:

- Patterns from few-shot examples (highest priority)
- User’s explicit rules
- User’s boilerplate phrases

-----

## Your Output Format

Generate a complete, ready-to-use A/P formatting prompt with these sections:

### Section 1: Task Description (1-2 sentences)

Brief, clear statement of what the prompt does.

### Section 2: Output Structure

Describe the exact format, matching the user’s examples:

- How problems/diagnoses are presented
- Bullet structure and content
- Spacing and organization
- Any conditional elements

### Section 3: Formatting Rules (numbered list)

Explicit instructions for:

1. Typography (bold, italics, etc.)
1. Indentation and spacing
1. Bullet styles
1. Brevity requirements
1. Abbreviation usage
1. Problem naming
1. Never fabricate information
1. Any other formatting specifics

### Section 4: Boilerplate Text (if applicable)

Include user’s boilerplate with clear conditional triggers:

- When to use each phrase
- How to format it (italics, placement, etc.)

### Section 5: Few-Shot Examples

Include the user’s examples exactly as provided, with the label:
“## Few-Shot Examples”

-----

## Quality Checks

Before outputting, verify your prompt:

1. Matches the user’s example patterns precisely
1. Includes all user-provided boilerplate
1. Incorporates explicit rules they mentioned
1. Is ≤5,000 characters (for EMR LLM constraint)
1. Uses plain text descriptions (no markdown in instructions)
1. Has clear, actionable formatting rules
1. Includes their exact few-shot examples

-----

## Important Constraints

- **Character limit**: Your output prompt must be ≤5,000 characters
- **Plain text only**: Describe formatting in words (e.g., “Bold the problem name” not “**Problem**”)
- **Preserve examples exactly**: Don’t modify the user’s few-shot examples
- **No fabrication**: Emphasize that the LLM should never infer missing information
- **Show don’t tell**: Few-shot examples are the most powerful teaching tool

-----

## Output Template Structure

```
[Task description - what this prompt does]

---

## Output Structure for Each Problem/Diagnosis

[Describe the format matching their examples]

---

## Formatting Rules

1. [Rule 1]
2. [Rule 2]
[etc.]

---

## Conditional Boilerplate Text

[If user provided boilerplate, include with condition formatted as below]

If condition discussed:
"Boilerplate text inserted here"

---

## Few-Shot Examples

[User's examples, exactly as provided]

---
```

-----

## Character Count

After generating the prompt, state:

- **Character count**: [X] / 5,000
- **Remaining headroom**: [Y] characters

If over 5,000 characters, identify what can be condensed without losing critical pattern information.

-----

## Example Interaction

**User provides:**

- 3 examples showing very brief bullets with clinical shorthand
- Explicit rule: “Never use section headers”
- Boilerplate: Standard illness return precautions

**You output:**
A complete prompt that:

- Matches their brief, shorthand style
- Omits section headers
- Includes their boilerplate with conditional logic
- Contains their 3 examples
- Stays under 5,000 characters
- Has numbered formatting rules

-----

## Ready to Begin

Take input user has provided with 

1. Their 3-5 few-shot examples of ideal A/P output
2. Any explicit formatting rules they want
3. Any boilerplate phrases for common scenarios

Then generate their custom A/P formatting prompt.

GUIDE: CREATING HIGH-PERFORMANCE CLINICAL FORMATTING PROMPTS


This guide synthesizes best practices for creating prompts that reformat
clinical text (like AI scribe output) into structured, physician-ready notes.
It is based on a "show, don't tell" philosophy.

CORE PRINCIPLES

1. EXAMPLES > INSTRUCTIONS (FEW-SHOT LEARNING)
   This is the most critical principle. Providing 3-5 high-quality examples
   of your desired output is far more effective than writing explicit
   instructions. The LLM excels at pattern recognition and will learn your
   implicit rules, tone, and structure from these examples.

2. BREVITY = QUALITY
   Concise prompts and concise outputs are better. Shorter notes are faster
   to scan, easier to edit, and reduce cognitive load.

3. ONE PROMPT, ONE PURPOSE (MODULAR)
   Specialized prompts outperform multi-function prompts. Trying to make one
   prompt do two things (e.g., write an A/P AND an after-visit summary)
   multiplies complexity and makes failure more likely.

ANATOMY OF A SUCCESSFUL PROMPT

A high-performance formatting prompt generally has five components, listed
in order of importance.

--- 1. THE FEW-SHOT EXAMPLES (MOST IMPORTANT) ---

This is the core of the prompt. Provide 3-5 complete examples of your exact
desired output. This is where the model learns your desired tone (e.g.,
formal vs. pithy), structure, and clinical shorthand.

--- 2. THE TASK STATEMENT ---

Begin the prompt with a clear, action-oriented instruction. Avoid "role-
prompting" (e.g., "You are a doctor"), as it adds length without improving
practical output.

Example: "Reformat the assessment and plan into a structured, problem-
oriented format."

--- 3. THE OUTPUT STRUCTURE ---

Explicitly show the SHAPE of your desired output. This can be a simple
bulleted list or a more formal structure with subheadings.

PITHY EXAMPLE:
**[Problem/Diagnosis Name]**
- [A very brief bullet point]
- [Another brief bullet point]

FORMAL EXAMPLE:
**[Problem/Diagnosis Name]**
Assessment:
· [Bullet summarizing diagnostic reasoning]
Plan:
· [Bullet for immediate interventions]
Next Steps:
· [Bullet for follow-up and return precautions]

--- 4. CONDITIONAL BOILERPLATE TEXT ---

This section automatically inserts your common "dot phrases" based on
triggers.

How it works: You define a trigger (e.g., "If well child check...") and the
text to add.

Pro-Tip: If you have trouble getting triggers to fire consistently, use
ICD-10 codes (e.g., "If diagnosis includes J06.9...") as they are very
reliable hooks.

Warning: Keep boilerplate text blocks short. Long blocks of text can confuse
the model and degrade output quality.

--- 5. THE FORMATTING RULES (Do this last) ---

This section is for minor, explicit rules that the examples don't perfectly
capture. This is the LAST place you should make edits.

Examples: "Bold formatting for problem names", "Omit unused sections
entirely", or "Indent all bullets with 8 spaces".

Based on the diagnoses in this note, generate a comprehensive checklist of commonly indicated orders, referrals, prescriptions, and follow-up items that may have been overlooked.

Output Structure
DIAGNOSIS: [Problem Name]
Consider ordering:

[Diagnostic test or imaging]
[Lab work]

Consider prescribing:

[Medication or supply]
[Durable medical equipment]

Consider referring:

[Specialist] for [specific reason]

Don't forget:

[Patient education materials]
[Follow-up scheduling]
[Other action items]

[Repeat for each diagnosis]

Rules

Only suggest items NOT explicitly mentioned in the note
Group by category: labs/imaging, medications/supplies, referrals, other
Be specific about indication (e.g., "Pulmonology for persistent control issues" not just "Pulmonology")
Prioritize common omissions over comprehensive lists
Use conditional language: "Consider" not "Must"
Keep each suggestion to one line
If everything was addressed appropriately, output: "All appropriate orders addressed in this visit."


Few-Shot Examples
Input: New asthma diagnosis, started albuterol
Output:
DIAGNOSIS: Asthma
Consider prescribing:

Spacer/aerochamber with mask (if age <4) or mouthpiece
Peak flow meter for home monitoring (if age ≥5)

Don't forget:

Asthma action plan (written copy for family)
Schedule follow-up in 2-4 weeks to assess control
Consider baseline spirometry if age ≥5 and cooperative


Input: ADHD, continued on Concerta 27mg, doing well
Output:
DIAGNOSIS: ADHD
Consider ordering:

Teacher Vanderbilt follow-up rating scale
Parent Vanderbilt follow-up rating scale

Don't forget:

Height and weight plotted on growth chart
Heart rate and blood pressure documented
Screen for mood changes, sleep issues, appetite changes
Follow-up in 3-6 months or PRN


Input: Type 1 diabetes, A1c 8.2%, increased basal insulin
Output:
DIAGNOSIS: Type 1 Diabetes
Consider ordering:

Celiac screen (tissue transglutaminase IgA + total IgA) if not done in past year
Thyroid screen (TSH) if not done in past year
Lipid panel if age >10 and not done in past year
Urine microalbumin if duration >5 years

Consider referring:

Ophthalmology for annual diabetic eye exam (if not seen in past year)
Endocrinology if not already established

Don't forget:

Review downloaded pump/CGM data
Assess for sick-day management plan understanding
Follow-up in 3 months


Input: Well child check, 15-month-old, vaccines given, growing well
Output:
DIAGNOSIS: 15-Month Well Child Visit
Consider ordering:

Hemoglobin/hematocrit (anemia screen)
Lead level (if not done at 12 months)

Don't forget:

Fluoride varnish application
Dental referral for first dental visit by age 1
M-CHAT screening tool for autism
Anticipatory guidance printed in AVS
Schedule 18-month well visit


Input: Strep throat, positive rapid test, started amoxicillin, RTC PRN
Output:
DIAGNOSIS: Streptococcal Pharyngitis
Don't forget:

Return to school after 24 hours of antibiotics
Emphasize completing full 10-day course even when feeling better
Replace toothbrush after 24 hours of antibiotics
Return precautions: worsening symptoms, persistent fever >48h, difficulty swallowing


Quality Checks
Before output:
✓ Only suggest items NOT already in the note
✓ Each suggestion is specific and actionable
✓ Grouped logically by category
✓ Uses conditional language ("Consider...")
✓ Focuses on common omissions, not exhaustive lists

ORDERS TO PLACE:  
[List a concise checklist of all labs, imaging, medications, referrals, or screenings mentioned above. Include each order even if already described under the problem list. Group by type (Labs, Imaging, Meds, Referrals, Other). This section is for provider task management and may repeat content from above.]

Are you using a different large language model from those listed here?  Please consider contributing your favorite prompt so others can benefit!  

Depending on the specific model your prompt may look different than those already here.  As these tools continue to improve we anticipate that the models will likely become even more intertwined and accessible from within the scribe products; if you're using a LLM within your scribe tool just submit it with the name of the tool (ex: Doximity, Dragon Copilot, Abridge, Heidi, Freed, etc). Thank you!