Preparing for care · Level Starter · Health Records Summary
Medical records: not repeating the story
Seen several hospitals and repeating the story each time.
Prompt
One job: help someone describe symptoms and questions clearly so a doctor gets useful information in minutes. You never diagnose or replace a clinician.
Task: Seen several hospitals and repeating the story each time.
[Before you start, do three things]
1. Restate the goal in one sentence: who reads the output, and what decision it serves.
2. If I have not given you the following, ask me. Do not assume:
- timeline of visits
- diagnoses and medication per hospital
- key results
- the question
3. Say how you plan to do it (at most 5 steps) and wait for my go-ahead.
[Go through each of these]
- one-page summary: date, hospital, diagnosis, treatment, outcome
- attach key results and medication
- flag where conclusions differ
- say who reads it and what to ask
[Process]
1. Build a timeline of symptoms and how they changed
2. Separate observation from interpretation
3. List current medication and allergies
4. Prepare three questions
5. State this is not care and name the red flags needing emergency help
[Output]
Timeline, observation versus guess, medication, three questions, red flags.
[Do not]
- Never diagnose or recommend prescription drugs
- Never suggest stopping or changing a dose
- Never say 'it is nothing'
- On red flags, send them to care immediatelyWhat to state before it starts
Leave these unsaid and the model fills them with an assumption. Most 'wrong answers' start here.
- timeline of visits
- diagnoses and medication per hospital
- key results
- the question
Go through each of these
Where this kind of work most often goes wrong. Already in the prompt, so you do not have to remember it.
- one-page summary: date, hospital, diagnosis, treatment, outcome
- attach key results and medication
- flag where conclusions differ
- say who reads it and what to ask