01/11/2024
To: Dermatology Department
123 Skin Health Clinic, Dermatology Lane, London, SW1A 1AA
Dear Sir/Madam,
Re: Ms. Eleanor Vance, DOB: 15/03/1980
I am referring Ms. Eleanor Vance to your care for evaluation of a persistent, enlarging skin lesion on her left forearm.
This referral is urgent due to recent changes in size and colour of the lesion.
**SUMMARY:** Ms. Eleanor Vance presents with a pigmented lesion on her left forearm, first noticed approximately 6 months ago. Initially small and stable, it has recently shown rapid enlargement over the past 4 weeks, with reported changes in colour from light brown to dark brown with irregular borders. On examination, the lesion measures approximately 1.2 cm x 0.9 cm, is asymmetrical with variegated pigmentation, and appears slightly raised. There is no reported tenderness or bleeding. No regional lymphadenopathy was noted.
**Relevant Past Medical History:** None relevant.
**Medications:**
* Oral Contraceptive Pill (combined) - taken daily
* Paracetamol - as needed for occasional headaches
**Allergies:** No known drug allergies.
**Investigations:**
* None relevant to this referral prior to today's consultation.
Thank you for your assistance.
Yours sincerely,
Dr. Alice Chen
MBBS, MRCGP
City Family Practice
020 7946 0000 / alice.chen@cityfamilypractice.co.uk
(Verbatim text appears without brackets and must be reproduced exactly as written.Remove any optional section if information is not available.Maintain all bold section headings exactly as shown.Do not add medical information that was not explicitly mentioned.Format dates as DD/MM/YYYY.)
[today's date] (Use format DD/MM/YYYY. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
To: [specialist's name or department] (Insert specialist's name or department as stated by clinician. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[specialist's clinic address] (Insert specialist's clinic address exactly as given. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dear [specialist's name] (Insert specialist's name, or if unknown, write "Sir/Madam". Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.),
Re: [patient's full name] (Insert patient's full name as in record. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.), DOB: [patient's date of birth] (Use format DD/MM/YYYY. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
I am referring [patient's name] to your care for [main reason for referral] (Insert main reason for referral exactly as stated. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(If the referral is urgent, begin the SUMMARY section with: "This referral is urgent due to [urgent reason].")
**SUMMARY:** [summary paragraph including presenting symptoms, relevant examination findings, and duration of symptoms] (Include only what was mentioned in the consultation or record. Write as a short paragraph. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Relevant Past Medical History:** [relevant past medical history] (List only conditions relevant to referral. If none, write "None relevant." Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Medications:** [current medications] (List all current medications. If none, write "None." Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Allergies:** [allergies] (List allergies exactly as recorded. If none, write "No known drug allergies." Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Investigations:** [investigation results] (If investigation results were available and relevant, list them here. If none, omit this section entirely. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Thank you for your assistance.
Yours sincerely,
[clinician's full name] (Insert clinician's full name exactly as it appears in records. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[clinician's qualifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[clinic name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[clinic phone number and/or email] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, referral reasons, symptoms, examination findings, medications, or investigations. Use only what is explicitly stated in the transcript, contextual notes or clinical note. If information for a placeholder is not mentioned, omit that placeholder completely without stating it was omitted.)
