130 lines
4.2 KiB
Markdown
130 lines
4.2 KiB
Markdown
# Ped-AI Template Guide
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Use this guide to write templates that the AI can follow reliably. Save each template in Settings > My Templates under the matching category.
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## General Rules
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- Use clear section headings ending with a colon.
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- Put one instruction or example per line.
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- Separate formatting preferences from clinical facts.
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- Do not include fake patient data unless it is clearly labeled as an example.
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- Use bracketed placeholders for variable content, such as `[age]`, `[chief complaint]`, or `[follow-up interval]`.
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- Tell the AI what to omit when data is missing.
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## Good Heading Style
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Chief Complaint:
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History of Present Illness:
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Review of Systems:
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Physical Examination:
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Assessment:
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Plan:
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## HPI Template Example
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History of Present Illness:
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Write one concise paragraph in third person.
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Start with age, sex, historian, and chief complaint.
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Use chronology first, then associated symptoms and pertinent negatives.
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Only include OLDCARTS details if they were provided.
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Do not invent fever height, duration, sick contacts, intake/output, severity, or home treatments.
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## Sick Visit Template Example
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Chief Complaint:
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[chief complaint]
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History of Present Illness:
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One paragraph with onset, duration, progression, treatments tried, response, relevant exposures, and pertinent positives/negatives only if documented.
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Review of Systems:
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Include systems reviewed. Expand normal systems with brief relevant negatives. Do not list systems not reviewed.
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Physical Examination:
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Use system headings. Include only examined systems. Expand normal findings with specific exam language.
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Assessment and Plan:
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1. [diagnosis or clinical assessment]
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Plan: [medications, supportive care, testing, return precautions, follow-up]
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## Well Visit Template Example
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Chief Complaint:
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Well child visit.
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Interval History:
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Parent concerns, development, growth, diet, sleep, elimination, school/daycare, behavior, safety, and interval illness if discussed.
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Review of Systems:
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Use age-appropriate systems. Only include findings reviewed or documented.
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Physical Examination:
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Use system headings. Include vitals and measurements if provided.
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Growth Assessment:
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Comment on growth pattern, BMI or weight-for-length when available, and whether growth is appropriate or needs follow-up.
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Screening Results:
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Document completed screenings and results only.
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Immunizations:
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Vaccines given, deferred, or refused if documented.
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Assessment:
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1. Well child visit - [age]
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2. Growth: [appropriate/concerning/deferred]
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3. Development: [appropriate/concerning/deferred]
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Plan:
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Nutrition/feeding counseling.
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Age-appropriate anticipatory guidance.
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Vaccines and screenings.
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Follow-up and next well visit.
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## ED Template Example
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Chief Complaint:
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[chief complaint]
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History of Present Illness:
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Use chronology and relevant positives/negatives. Do not force every OLDCARTS element.
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Physical Examination:
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Focused exam with abnormal findings first when relevant.
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ED Course:
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Diagnostics, treatments, reassessments, consults, and response in chronological order.
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Assessment and Plan:
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Problem-oriented assessment. Include disposition only when documented.
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## Physical Exam Template Example
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General: Well-appearing, alert, interactive, in no acute distress.
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HEENT: Normocephalic, atraumatic. TMs clear bilaterally. Oropharynx clear without erythema or exudate.
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Neck: Supple, full range of motion, no lymphadenopathy.
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Respiratory: Clear to auscultation bilaterally, no wheezes, crackles, or retractions.
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Cardiovascular: Regular rate and rhythm, no murmur, brisk capillary refill.
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Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds.
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Skin: Warm, dry, no rash.
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Neurologic: Alert, age-appropriate, no focal deficit observed.
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## Assessment And Plan Template Example
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Assessment:
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1. [Diagnosis or clinical problem]
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Supporting findings: [brief rationale]
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Plan:
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Medications:
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Testing:
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Supportive care:
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Return precautions:
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Follow-up:
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## Common Mistakes To Avoid
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- Do not paste a complete note with fake patient facts and expect the AI to ignore them.
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- Do not use vague instructions like "make it good" or "standard plan".
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- Do not mix multiple note types in one template unless that is intentional.
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- Do not include billing claims or diagnosis certainty that should depend on the encounter.
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