# Ped-AI Template Guide

Use this guide to write templates that the AI can follow reliably. Save each template in Settings > My Templates under the matching category.

## General Rules

- Use clear section headings ending with a colon.
- Put one instruction or example per line.
- Separate formatting preferences from clinical facts.
- Do not include fake patient data unless it is clearly labeled as an example.
- Use bracketed placeholders for variable content, such as `[age]`, `[chief complaint]`, or `[follow-up interval]`.
- Tell the AI what to omit when data is missing.

## Good Heading Style

Chief Complaint:
History of Present Illness:
Review of Systems:
Physical Examination:
Assessment:
Plan:

## HPI Template Example

History of Present Illness:
Write one concise paragraph in third person.
Start with age, sex, historian, and chief complaint.
Use chronology first, then associated symptoms and pertinent negatives.
Only include OLDCARTS details if they were provided.
Do not invent fever height, duration, sick contacts, intake/output, severity, or home treatments.

## Sick Visit Template Example

Chief Complaint:
[chief complaint]

History of Present Illness:
One paragraph with onset, duration, progression, treatments tried, response, relevant exposures, and pertinent positives/negatives only if documented.

Review of Systems:
Include systems reviewed. Expand normal systems with brief relevant negatives. Do not list systems not reviewed.

Physical Examination:
Use system headings. Include only examined systems. Expand normal findings with specific exam language.

Assessment and Plan:
1. [diagnosis or clinical assessment]
Plan: [medications, supportive care, testing, return precautions, follow-up]

## Well Visit Template Example

Chief Complaint:
Well child visit.

Interval History:
Parent concerns, development, growth, diet, sleep, elimination, school/daycare, behavior, safety, and interval illness if discussed.

Review of Systems:
Use age-appropriate systems. Only include findings reviewed or documented.

Physical Examination:
Use system headings. Include vitals and measurements if provided.

Growth Assessment:
Comment on growth pattern, BMI or weight-for-length when available, and whether growth is appropriate or needs follow-up.

Screening Results:
Document completed screenings and results only.

Immunizations:
Vaccines given, deferred, or refused if documented.

Assessment:
1. Well child visit - [age]
2. Growth: [appropriate/concerning/deferred]
3. Development: [appropriate/concerning/deferred]

Plan:
Nutrition/feeding counseling.
Age-appropriate anticipatory guidance.
Vaccines and screenings.
Follow-up and next well visit.

## ED Template Example

Chief Complaint:
[chief complaint]

History of Present Illness:
Use chronology and relevant positives/negatives. Do not force every OLDCARTS element.

Physical Examination:
Focused exam with abnormal findings first when relevant.

ED Course:
Diagnostics, treatments, reassessments, consults, and response in chronological order.

Assessment and Plan:
Problem-oriented assessment. Include disposition only when documented.

## Physical Exam Template Example

General: Well-appearing, alert, interactive, in no acute distress.
HEENT: Normocephalic, atraumatic. TMs clear bilaterally. Oropharynx clear without erythema or exudate.
Neck: Supple, full range of motion, no lymphadenopathy.
Respiratory: Clear to auscultation bilaterally, no wheezes, crackles, or retractions.
Cardiovascular: Regular rate and rhythm, no murmur, brisk capillary refill.
Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds.
Skin: Warm, dry, no rash.
Neurologic: Alert, age-appropriate, no focal deficit observed.

## Assessment And Plan Template Example

Assessment:
1. [Diagnosis or clinical problem]
Supporting findings: [brief rationale]

Plan:
Medications:
Testing:
Supportive care:
Return precautions:
Follow-up:

## Common Mistakes To Avoid

- Do not paste a complete note with fake patient facts and expect the AI to ignore them.
- Do not use vague instructions like "make it good" or "standard plan".
- Do not mix multiple note types in one template unless that is intentional.
- Do not include billing claims or diagnosis certainty that should depend on the encounter.
