1 November 2024
Dear Dr. Eleanor Vance,
Re: Ms. Sarah Jenkins
File: SJ-987654
"Thank you for seeing the patient below."
I am writing to refer my patient, Ms. Sarah Jenkins, who is known with chronic migraines [G43.909], cervical spondylosis [M47.812], and a history of a lumbar discectomy (L5-S1) in 2020 [M51.26] and is currently using sumatriptan 50mg PRN, amitriptyline 25mg nightly, and ibuprofen 400mg PRN.
They presented today with the following problem:
Ms. Jenkins reports a significant increase in the frequency and intensity of her chronic migraines over the past three months, now occurring almost daily with accompanying visual aura and phonophobia. She also describes new-onset right arm paraesthesia and weakness, particularly in her grip, which she attributes to her cervical spondylosis, noting it has worsened over the last two weeks. Previous conservative management, including physical therapy and oral analgesics, has not provided adequate relief for her cervical symptoms. She is concerned about the impact on her daily activities and work.
Your expertise would be greatly appreciated in assisting with further management strategies for this patient.
"Thank you for your attention to this matter."
Yours sincerely,
Dr. Thomas Kelly
Neurosurgeon
MD-1234567
[Insert today’s date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Dear [Insert name and title of clinician the letter is addressed to] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.),
Re: [Insert patient’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
File: [Insert file number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"Thank you for seeing the patient below."
I am writing to refer my patient, [Insert patient’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely), who is known with [Insert known medical conditions including past diagnoses, chronic diseases, or relevant background medical history with ICD-10 codes in brackets next to each diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) and is currently using [Insert medications including prescription medications, over-the-counter medications, and supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely).
They presented today with the following problem:
[Insert history of presenting complaint, current concerns or symptoms, clinical context, relevant background to the issue, and discussion topics covered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences.)
Your expertise would be greatly appreciated in assisting with further management strategies for this patient.
"Thank you for your attention to this matter."
Yours sincerely,
[Insert clinician title, name and surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert clinician specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert clinician registration or provider numbers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the section entirely. Never come up with your own patient details, medical history, symptoms, diagnoses, assessments, management plans, medications, or clinician details. Use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Maintain the original structure and tone of the letter, and do not insert generic statements or assumptions.)