Neurosurgery Patient Consultation Letter

Date [Document the date of dictation] (Always use the date of dictation for the letter date. If not explicitly available in the transcript, contextual notes or clinical note, omit this entire line completely. Do not infer or calculate a date.) [Document the patient's full name including title], DOB [Document the patient's date of birth], Hospital Number: [Document the hospital number] (Only include identifiers explicitly mentioned in the transcript, contextual notes or clinical note. Always include the patient's title such as Mr, Mrs, Ms, Miss or Dr if explicitly provided. If title is not specified, omit the title. If date of birth or hospital number are not mentioned, omit those individual elements. Do not invent missing identifiers.) [Document the patient's address] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Write exactly as provided. Omit completely if not stated.) Dear [Document the patient's title] [Document the patient's surname], (Only include if both title and surname are explicitly mentioned in the transcript, contextual notes or clinical note. Do not infer title or surname. Omit greeting entirely if insufficient details are provided.) **Diagnoses:** 1. [Document the clinician's explicitly stated primary diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. State the diagnosis concisely using the exact terminology provided. Do not infer, reinterpret or expand the diagnosis.) 2. [Document the relevant past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Include only history directly stated. Do not infer relevance or completeness.) **Management Plan:** [Document the summary of the management plan including investigations and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Present as a concise numbered list reflecting exactly what was discussed. Do not introduce new management steps.) **History:** It was a pleasure to see you at [Clinic name and location] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit entirely.) on [Document the appointment date] (Always use the date of dictation if explicitly stated. If no date is available in the transcript, contextual notes or clinical note, omit only the date and retain the sentence. Do not fabricate a date.) to review your health concerns. You are [Document the patient's age] (If the patient's age is explicitly mentioned in the transcript, contextual notes or clinical note, insert the stated age. If age is not mentioned, write exactly: "Clinician to provide age." Do not calculate age from date of birth.) years old and I appreciate the time you took to share details about your health and personal life. I have summarised our discussion below. [Document the chief complaint and onset details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Write in a formal narrative style beginning with phrases such as "You explained that..." or "You described...". Do not introduce symptoms not directly stated.) [Document the current symptom status and management strategies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Write in flowing formal paragraphs describing the current condition and management exactly as stated. Do not embellish.) [Document the associated symptoms discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Include relevant positive and negative symptoms only if directly discussed. Do not add routine negatives.) [Document the past medical history details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Include surgical history, allergies and relevant medical conditions exactly as stated. Do not assume completeness.) [Document the social history and functional status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Include occupation, living situation, substance use and functional capacity only if directly discussed. Do not infer lifestyle details.) On examination, [Document the examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Write in detailed formal paragraphs covering all examination components performed exactly as described. Omit the entire sentence if no examination findings are provided.) We discussed that [Document the clinical impression and explanation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Provide formal explanation using clinician’s wording. Do not introduce a new diagnosis.) [Document the investigation rationale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Omit if not discussed.) [Document the follow-up arrangements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Do not fabricate timelines.) [Document the red flag warning signs discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Include specific symptoms and escalation advice only if directly discussed.) Yours sincerely **[Document the clinician's full name and credentials]** (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Write exactly as provided. Omit entirely if not available.) **[Document the clinician's professional title]** (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Do not assume specialty.) **[Document the clinician's contact email address]** (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Format exactly as: "Enquiry: [email address]". Omit entirely if not provided.) **[Document the clinician's professional weblink]** (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. Format exactly as: "Weblink: [URL]". Omit entirely if not provided.) cc: GP [Document the GP name], [Document the GP address] (Only include if GP details are explicitly mentioned in the transcript, contextual notes or clinical note. Do not infer GP information. Omit entirely if not provided.)