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Internal Medicine Specialist Template

Report to Referring Doctor

A professional Internal Medicine Specialist template for healthcare professionals.
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About this template

Need to send a detailed medical report to a referring doctor? This 'Report to Referring Doctor' template is perfect for Internal Medicine specialists. It allows for a comprehensive summary of a patient's condition, including presenting complaints, medical history, examination findings, and management plans. With Heidi, the AI scribe, this template can be quickly populated from your patient consultations, ensuring all relevant information is captured accurately and efficiently. This helps streamline communication with other healthcare professionals, improving patient care and saving valuable time.

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01/11/2024 Dr. Eleanor Vance Consultant Cardiologist St. Jude's Hospital London, UK Dear Dr. Vance, Re: Mr. David Miller Date of birth: 12/03/1960 Diagnosis: * Hypertension * Hyperlipidaemia Presenting complaint and history: Mr. Miller presented today with a complaint of increasing shortness of breath over the past two weeks, especially on exertion. He denies chest pain or palpitations. He reports a history of hypertension, diagnosed five years ago, and hyperlipidaemia, diagnosed three years ago. He has been compliant with his medication regimen, including lisinopril 20mg daily and atorvastatin 40mg daily. He reports no recent changes to his medication or lifestyle. Relevant negatives: Denies chest pain, palpitations, dizziness, or syncope. No recent cough or fever. Past medical history: Hypertension, hyperlipidaemia, and a history of smoking (quit 10 years ago). On examination: General examination findings: Alert and oriented. Mildly overweight. Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths/min, SpO2 98% on room air. Systemic examination findings: Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No peripheral oedema. Pathology: Relevant pathology results: Lipid panel: LDL 3.5 mmol/L, HDL 1.2 mmol/L, triglycerides 1.8 mmol/L. Renal function tests within normal limits. Course and management: Discussed the importance of blood pressure control and lifestyle modifications. Continued current medication regimen. Advised regular exercise and a low-fat diet. Referred for a cardiology consultation. Additional investigations and findings: ECG showed normal sinus rhythm. Final diagnosis and outcome: Hypertension and hyperlipidaemia, stable but requiring further investigation of shortness of breath. Referred to cardiology for further assessment. With best regards, Dr. Thomas Kelly Internal Medicine Specialist
[Date] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Recipient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Recipient contact details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Dear [Recipient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Re: [Patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Date of birth: [DD/MM/YYYY] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Diagnosis: [Diagnosis 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Diagnosis 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Diagnosis 3] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Presenting complaint and history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant negatives] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) On examination: [General examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Vital signs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Systemic examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Pathology: [Relevant pathology results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) Course and management: [Clinical course and management] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Additional investigations and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Final diagnosis and outcome] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Attachments if relevant] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) With best regards, [Clinician name or signature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
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Specialty

Internal Medicine Specialist

Used

49 times

Type

Note

Last edited

26.8.2025

Created by

Gerard Van Aswegen

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