Dear Aviva Insurance,
I, Dr. Eleanor Vance, have been the treating General Practitioner for John Smith, born 12/03/1978 at The Grove Medical Practice, London since 10/06/2023. Please see my responses below pertaining to all questions asked of me as the provider, answered to the best of my knowledge on reviewing all clinical notes and results that I have access to at this clinic. All relevant results will be included as an attachment following this report.
**Hypertension:**
Mr. Smith was diagnosed with hypertension on 10/06/2023. He presented with headaches and reported a family history of hypertension. Examination revealed an elevated blood pressure of 160/95 mmHg. Investigations included a full blood count, renal function tests, and an ECG, all of which were within normal limits except for the elevated blood pressure. He was referred to a cardiologist for further evaluation. Treatment provided included lifestyle advice (diet and exercise) and medication (Lisinopril 10mg daily). Follow-up appointments were scheduled every 3 months to monitor blood pressure and medication effectiveness.
**Type 2 Diabetes:**
Mr. Smith was diagnosed with Type 2 Diabetes on 15/08/2023. He presented with increased thirst, frequent urination, and fatigue. Examination revealed a blood glucose level of 15.2 mmol/L. Investigations included a HbA1c test, which showed a level of 9.2%. He was referred to a diabetes nurse educator for advice on diet and lifestyle changes. Treatment provided included Metformin 500mg twice daily and lifestyle modifications. Follow-up appointments were scheduled every 3 months to monitor blood glucose levels and medication effectiveness.
I can confirm that the information in this report is true and correct and that no other information has been omitted at the patient's request.
Doctor's signature: _________________________
Dated: 01 November 2024
Doctor's name: Dr. Eleanor Vance
Qualifications: MBBS, MRCGP
Doctor's address: The Grove Medical Practice, 123 Grove Street, London, UK
Doctor's phone number: 020 7123 4567
Dear [insert name of insurer company],
I, [treating doctor’s full name], have been the treating General Practitioner for [full patient name and date of birth] at [clinic name and location] since [date the patient commenced care at this clinic]. Please see my responses below pertaining to all questions asked of me as the provider, answered to the best of my knowledge on reviewing all clinical notes and results that I have access to at this clinic. All relevant results will be included as an attachment following this report.
[summary of each condition under management, including condition name, relevant visit dates, presenting symptoms, examination findings, investigations performed, referrals made, and treatment provided. Repeat this format for each separate condition discussed in the report] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences. Repeat this section for each condition described in the context.)
I can confirm that the information in this report is true and correct and that no other information has been omitted at the patient's request.
Doctor's signature: _________________________
Dated: [insert today’s date]
Doctor's name: [treating doctor’s full name]
Qualifications: [list medical qualifications]
Doctor's address: [clinic name and address]
Doctor's phone number: [clinic contact number]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)