Medical Record Review Prompts

Get a plain-English summary

Summarise this medical record in plain English. What type of document is it, who is the patient, what is the primary reason for the visit or admission, and what are the main findings or outcomes recorded?

List all diagnoses and clinical findings

What diagnoses, clinical findings, or conditions are recorded in this document? List each one clearly, note whether it is described as confirmed, suspected, or ruled out, and identify where in the document it appears.

Extract all test and lab results

What tests, investigations, scans, or lab results are recorded in this document? For each one, tell me what was tested, what the result was, and whether the document describes the result as normal, abnormal, or requiring follow-up.

List all medications and dosages

What medications are mentioned in this document? List each one with the dosage, frequency, and route of administration as recorded. Note whether each medication is a new prescription, a continuation, or a change from a previous prescription.

Summarise the treatment plan

What treatment plan, care plan, or recommended course of action is described in this document? Include any procedures, therapies, lifestyle changes, or monitoring requirements that are specified.

Find all follow-up instructions and appointments

What follow-up actions, appointments, or instructions are recorded in this document? List each one, note who is responsible for arranging it, and include any timeframes or conditions specified.

Identify any referrals made

Does this document record any referrals to other clinicians, specialists, or services? For each referral, tell me who the referral is to, the reason given, and any urgency or priority indicated in the document.

Find allergies and documented warnings

Does this document record any allergies, intolerances, adverse reactions, or clinical warnings? List each one exactly as recorded, including the substance or trigger and the type of reaction noted.

Extract dates and build a timeline

List all dates mentioned in this document, including the date of this record, dates of previous events referenced, and any future dates for appointments or review. Arrange them in chronological order and describe what happened or is scheduled for each one.

Generate questions to ask my doctor

Based only on what this medical record states, what are the most important questions I should ask my doctor at my next appointment? Focus on anything that is unclear, requires a decision, or has a follow-up action attached to it.

Summarise key concerns and next steps

Based on what this document actually states, what are the most important things I need to be aware of or act on? For each one, identify which part of the document it comes from and explain why it matters.