Medical consult summary

Cuándo usar esta plantilla

• After a medical consult so the patient has a record
• For the healthcare professional's file
• To sync with another specialist

Qué incluye

• MANDATORY medical notice at the START (no diagnosis, no prescription)
• Reason for consultation
• History (reported symptoms)
• Examination (only what was mentioned)
• Preliminary clinical impression (only if practitioner verbalizes it)
• Agreed plan (medication, tests, referrals)
• Next appointment or follow-up

Ejemplo de output

# Consult summary · November 12, 2026

## Important medical notice
IMPORTANT — This document is an automated AI-generated summary based on a recording. It does NOT constitute a diagnosis, prescription or medical recommendation. It does NOT replace the clinical judgment of a licensed healthcare professional. Any decision regarding treatment, medication or procedure must be based exclusively on the direct evaluation of a physician. If you have severe symptoms, contact emergency services.

## Reason for consultation
Persistent lower back pain for 3 weeks.

## History
Gradual onset pain with no associated trauma. Worse on rising and improves with movement. No radiation.

## Examination
No specific vital parameters mentioned during the recording.

## Agreed plan
- Relative rest 1 week
- NSAID prescribed by the practitioner
- If no improvement in 10 days, follow-up + possible physiotherapy referral

Output ilustrativo. El resultado real lo genera la IA a partir del contenido específico de tu nota.

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