Neurosurgery Patient Consultation Letter

(Write this entire letter directed at the patient, consistently referring to them in the second person as “you.”) Date: [Date of the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Patient name with title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), DOB [Patient date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), Hospital Number: [Patient hospital number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Patient address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on one line separated by commas.) Dear [Patient title and surname] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), Diagnoses: 1. [Primary diagnosis as stated explicitly by the clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 2. [Relevant past medical and surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Management Plan: [Summary of the discussed management plan including investigations and follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a concise numbered list.) History: ”It was a pleasure to see you on [Date of the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) to review your health concerns. You are [Patient age in years] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) years old and I appreciate the time you took to share details about your health and personal life. I have summarised our discussion below.” [Chief complaint and details of its onset] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in a formal narrative style in paragraphs of full sentences.) [Current status of symptoms and the patient's management strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [Associated symptoms discussed, including relevant positive and negative findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [Past medical history including surgical history, allergies and relevant medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [Social history and functional status including occupation, living situation, substance use and functional abilities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) On examination, [Findings from the clinical examination performed, covering all examination components conducted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) We discussed that [Clinical impression and explanation provided to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in a formal style in paragraphs of full sentences.) [Rationale for any investigations ordered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Follow-up arrangements discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Red flag warning signs discussed with the patient, including specific symptoms to monitor and when to seek urgent care] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) ”Yours sincerely” [Clinician full name and credentials] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Clinician title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Clinician contact email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Format as 'Enquiry: [email address]'.) [Clinician professional web address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Format as 'Weblink: [URL]'.) cc: GP [Referring GP name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Referring GP practice address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)