Letter Back to Referring Clinician (RK paediatrics)

[Patient name and date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Dear Dr [referring clinician surname] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), Problem(s) list: [Clinician's explicitly stated diagnoses and active problems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a bullet point list.) Investigations: [Investigations ordered or results discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence form.) Medications: [Current medications including name, dose and frequency] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Weight: [Patient's recorded weight including units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Height: [Patient's recorded height including units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Introductory summary including who was present at the consultation, reason for attendance, clinical progress update and relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) On examination: [Clinical examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Discussion: [Summary of clinical discussion including concerns raised, decisions made and topics explored during the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: [Management plan including treatments, referrals, follow-up arrangements and any instructions given to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Follow up: [Follow-up arrangements including timeframe and responsible clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence form.) Copy to: [Full names of individuals to receive a copy of the letter] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)