Medical Diagnosis Report Notes for Claims or Leaves

Administrative Details: - Date of Report: [Enter Date of Report] (only include if explicitly mentioned, provide the date the medical diagnosis report is created) - Patient Name: [Enter Patient Name] (only include if explicitly mentioned, provide the full legal name of the patient) - Date of Birth: [Enter Patient Date of Birth] (only include if explicitly mentioned, used to identify the patient's age for relevant medical conditions) - Report Prepared By: [Enter Report Preparer’s Name and Credentials] (only include if explicitly mentioned, provide the name and credentials of the healthcare professional preparing the report) Reason for Report: - Purpose: [Enter Purpose of Report] (only include if explicitly mentioned, describe the reason for the report, such as to provide a diagnosis, disability assessment, or support for medical leave) - Referral Source: [Enter Referral Source] (only include if relevant, provide the name or source of the referral for the diagnosis) Medical History: - Previous Medical Conditions: [Enter Previous Medical Conditions] (only include if relevant, summarize the patient's medical history, including any chronic conditions or previously diagnosed illnesses) - Current Medications: [Enter Current Medications] (only include if relevant, list medications the patient is currently taking, including dosage and frequency) - Allergies: [Enter Allergies] (only include if relevant, list known allergies, especially drug allergies) Presenting Complaint: - Chief Complaint: [Enter Chief Complaint] (only include if explicitly mentioned, describe the patient's primary complaint or reason for seeking medical care) History of Present Illness: - Onset of Symptoms: [Enter Onset of Symptoms] (only include if relevant, describe the onset and duration of the patient’s symptoms) - Associated Symptoms: [Enter Associated Symptoms] (only include if relevant, list any associated symptoms the patient is experiencing along with the chief complaint) - Previous Treatments: [Enter Previous Treatments] (only include if relevant, describe any previous treatments or interventions related to the current condition) Diagnostic Findings: - Diagnostic Tests Ordered: [Enter Diagnostic Tests Ordered] (only include if relevant, list any tests or examinations ordered, such as lab work, imaging, etc.) - Laboratory Test Results: [Enter Laboratory Test Results] (only include if relevant, provide results of blood tests, urine tests, or other laboratory investigations) - Imaging Results: [Enter Imaging Results] (only include if relevant, describe any imaging results, such as X-rays, MRIs, or CT scans, including findings) - Specialist Consultations: [Enter Specialist Consultations] (only include if relevant, include any consultations or second opinions from specialists related to the diagnosis) Diagnosis: - Primary Diagnosis: [Enter Primary Diagnosis] (only include if relevant, provide the diagnosis based on the medical evaluation and diagnostic findings) - Secondary Diagnoses: [Enter Secondary Diagnoses] (only include if relevant, provide any additional diagnoses that may be contributing to the patient’s condition) - ICD-10 Codes: [Enter ICD-10 Codes] (only include if relevant, list the appropriate ICD-10 codes for each diagnosis) Plan of Care: - Initial Treatment: [Enter Initial Treatment Plan] (only include if relevant, describe the treatment plan to address the diagnosis, including medications, therapies, or procedures) - Referrals: [Enter Referrals Made] (only include if relevant, list any referrals to specialists or other healthcare providers) - Follow-Up Appointments: [Enter Follow-Up Appointments] (only include if relevant, provide any follow-up appointments scheduled to reassess the condition) Prognosis: - Expected Outcome: [Enter Expected Prognosis] (only include if relevant, provide the expected prognosis for the patient, including likelihood of recovery or progression of the condition) - Disability or Work Restrictions: [Enter Disability or Work Restrictions] (only include if relevant, describe any work restrictions or limitations due to the diagnosis) Recommendations: - Recommended Treatment: [Enter Recommended Treatment] (only include if relevant, describe any recommended treatments or interventions, including medications, physical therapy, etc.) - Lifestyle Modifications: [Enter Lifestyle Modifications] (only include if relevant, recommend any lifestyle changes or adjustments needed to support recovery) - Work/Disability Recommendations: [Enter Work or Disability Recommendations] (only include if relevant, recommend the patient’s eligibility for medical leave, disability claims, or necessary work accommodations) Certification: I, [Enter Report Preparer’s Name], hereby certify that the information provided in this report is accurate and complete to the best of my knowledge and belief. This diagnosis is based on the patient’s medical records, diagnostic findings, and clinical evaluation. - GP’s Name and Signature: [Enter GP Name and Signature] (only include if relevant, provide the name and signature of the healthcare professional preparing the report) - GP’s Credentials: [Enter GP Credentials] (only include if relevant, provide the credentials of the healthcare professional preparing the report) - Date: [Enter Date of Report Preparation] (only include if relevant, provide the date the report was prepared) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)