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提示词_8_4_72

Instructions:

You are an experienced medical expert tasked with generating a standardized outpatient medical record in JSON format based on the conversation between the doctor and the patient. Your response must adhere to clinical outpatient documentation standards and provide a comprehensive and structured report. The output must be in JSON format as specified below and in English.

Prompt Template

{
  "visitSummary": "string",
  "subjective": "string",
  "objective": "string",
  "assessmentAndPlan": "string",
  "patientInstructions": "string",
  "transcriptSummary": "string",
  "patientName": "string",
  "patientBasicInformation": {
    "name": "string",
    "age": "string"

  }
}

Field Descriptions

  • visitSummary:

    • Provide a concise summary of the patient is visit in English. This should include key complaints, clinical findings, and the overall management plan.

  • subjective:

    • Document the patient is reported symptoms, chief complaint, and relevant personal, family, and past medical history as expressed during the consultation. Ensure the information is accurate and written in professional English.

  • objective:

    • Include detailed findings from the physical examination, vital signs, and results from any auxiliary examinations (e.g., laboratory tests or imaging studies). Present this information clearly and professionally in English.

  • assessmentAndPlan:

    • Record the clinical assessment, including the primary diagnosis, differential diagnoses, and the proposed treatment plan. This should cover prescribed medications, lifestyle recommendations, and any further diagnostic or therapeutic interventions. Write this section using formal medical terminology in English.

  • patientInstructions:

    • Summarize the instructions provided to the patient regarding treatment, lifestyle changes, follow-ups, or other relevant recommendations. The instructions should be clear and easy to understand in English.

  • transcriptSummary:

    • Provide a high-level summary of the dialogue or interaction between the doctor and the patient. Capture the key points discussed and outcomes in fluent English. Output the original fluent dialogue content with roles assigned.

  • patientName:

    • Include the name of the patient as mentioned in the conversation.

  • patientBasicInformation:

    • Include basic information about the patient, such as name and age.

Constraints

  • The output must be written entirely in English.
  • Follow professional medical documentation standards, ensuring clarity, accuracy, and relevance.
  • The JSON structure provided above is mandatory and must not be altered.
  • Use concise and formal language suitable for a medical record.
  • When a theme contains multiple related points, present them within a list format to ensure clarity and organization

病历_8_4_72

{
  "visitSummary": "The patient returned for a follow-up regarding elevated cholesterol levels, which remain above 200 mg/dL. Despite adjusting the dosage of cholesterol-lowering medication to 10 mg, there has been no significant improvement. Liver function tests are normal this visit.",
  "subjective": "The patient reports that since the last follow-up, cholesterol levels have remained over 200 mg/dL, with a slight increase in LDL levels. The patient has reduced the dosage of cholesterol-lowering medication from 20 mg to 10 mg. Previously, liver function tests were slightly elevated but are normal this time. The patient has no other significant discomforts.",
  "objective": "Vital signs, including blood pressure and blood glucose levels, were not specified. Cholesterol levels are above 200 mg/dL, with a slight increase in LDL. Liver function is normal compared to the previous visit.",
  "assessmentAndPlan": "1. Hypercholesterolemia (slight increase in LDL). 2. Normal liver function. 3. Continue monitoring cholesterol and related parameters. Treatment Plan: 1. Continue with 10 mg of Phenofibrate and advise discontinuation of Libido. 2. Recommend adding Omega-3 fish oil supplements to aid in lowering cholesterol. 3. Schedule a follow-up cholesterol level check in three months and adjust treatment based on results. 4. Remind the patient to check flu and COVID-19 vaccination status. 5. Address the patient's concerns regarding examination costs and procedures, advising them to research these details for upcoming exams in Taiwan.",
  "patientInstructions": "Continue taking 10 mg of Phenofibrate. Start Omega-3 fish oil supplements. Return in three months for a cholesterol check. Stay updated on flu and COVID-19 vaccinations. Consider researching examination costs and processes for further evaluations.",
  "transcriptSummary": "Patient: I am back for a follow-up, and my cholesterol level is still above 200 mg/dL, with no significant improvement. Doctor: Your LDL levels have slightly increased since your last visit, and the liver function tests are now normal. Let's continue with the 10 mg medication and add Omega-3 supplements. We will check your levels again in three months.",
  "patientName": "季伊博",
  "patientBasicInformation": {
    "name": "季伊博",
    "age": "not specified"
  }
}