Shoulder Surgeon's Note

Name: [patient's first and last name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) [opening statement thanking for the referral] (Only include for new appointments if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. For follow-up or review appointments, omit any referral acknowledgment references. Write as: Thank you for referring [Patients first name only] who was seen in the Shoulder clinic today. If it is a follow-up or review appointment remove any "thank you for referral" references and don't include an examination findings section.) Diagnosis: [the clinician’s concise diagnosis and how it relates to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis. List each diagnosis on a new line with no bullet points and a full stop at the end of each line. Never use dashes at the start of a list.) Plan: [brief plan to manage condition or injury including when the patient is planned to next be seen in clinic for review or if they are discharged from follow-up] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. List each plan on a new line with no bullet points and a full stop at the end of each line. Never use dashes at the start of a list.) [brief summary of presenting complaint or history of complaint including patient's age and handedness, occupation, reason for visit, current issues, who was in attendance with the patient, employment status, type of work, leisure interests and activities] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [any other associated symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [functional limitations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [treatment facilitated to date including medications, therapy, or other interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) Past Medical History: [medical and surgical history, family history, social history, allergies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) Medications: [list of medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. List each medication on a new line with no bullet points. Never use dashes at the start of a list.) On Examination: [physical or mental state examination findings including system specific examinations] (Only include for new appointments if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. For follow-up or review appointments, omit this section. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [imaging findings and any relevant interpretations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [document the discussions with the patient on options for future investigations and management options] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [investigations planned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [treatment planned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [relevant other actions such as counselling, referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write in paragraphs of full sentences with proper punctuation. Do not use bullet points.) [closing statement thanking for the referral] (Only include for new appointments if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. For follow-up or review appointments, omit this closing statement.) [clinician name and credentials] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) (Always refer to the patient using their first name only. Never refer to the patient using titles. Use only the first name.)