ENT H&N F/U Patient Clinic Letter

**Diagnosis** [Cancer diagnosis including TNM stage, taken from transcript or from context. Also include treatment with dates of surgical procedures and completion of other therapy e.g. chemo or radiotherapy if applicable. If there is no specific day given, write the month and year] **Current Issues** [Include any problems that the patient is experiencing relating to the above, as a numbered list and grouping similar symptoms together] **Background** [Key diagnoses, both ENT and non-ENT, should be listed here, in addition to a timeline of the patient’s previous ENT surgical procedures and investigations to date, with dates if available. Each investigation should have a summary of the radiologist’s report in less than 10 words, if available. List conditions as Past Medical History following this.] **Impression** - [provide clinical impression or diagnosis. If the patient has a diagnosis of a treated cancer and is stable, additionally write "No clinical features to suggest local or regional recurrence] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **Plan** - [outline management plan and planned investigations, treatment options, follow-up arrangements etc - specifically when the next appointment will be and the timeframe for this] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **Requested GP Actions** - [any outstanding actions for their GP to arrange, including initiation of new medications on repeat prescription] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **Assessment** [Address the remainder of the letter to the patient, in the second person, written in prose in coherent sentences. Start with: "We met in our Head and Neck Clinic today, alongside [list any attending relatives/friends here if applicable]. Also present were [List all members of the multidisciplinary team and their titles as dictated] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Write the patient's current issues in prose, not bullet points, describing: current ENT issues, reasons for visit, discussion topics, history of presenting complaints etc and important negative findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Examination Findings: - [describe examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [End with a summary in two sentences to describe the next steps in management/follow up and conclude the letter] **Copy to:** [If referenced, list the names of any teams or specific doctor and their specialties who should be copied in to this letter, each separated by a semicolon. If there is a plan to refer for a hearing aid, include "Audiology Department in this section". If there is a plan to refer to speech and language therapy or voice therapy, include "Speech and Language Therapy" in this section. Follow each on a new line with a 2-line referral letter summary relevant to that recipient.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and exclude “Copy to” title from text) (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 include 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 section blank.)(Use as many full sentences as needed to capture all the relevant information from the transcript.)