General Surgery Clinic Letter

Diagnosis: [All diagnoses explicitly stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a numbered list with each diagnosis on a new line.) Past Medical and Surgical History: [All past medical conditions and past surgical procedures explicitly mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each condition or procedure on a new line, grouping medical history first followed by surgical history.) Plan: [All aspects of the management plan explicitly discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each plan item on a new line.) [Summary of the patient's diagnosis and past medical and surgical history, forming the opening paragraph of the letter body] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a paragraph of full sentences. Any numbers under ten must be written as words except for measurements.) [Summary of the patient's social history and family history, followed by an accurate list of all current medications with their specific dosages as stated in the transcript; capitalise all medication names] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a paragraph of full sentences. Do not invent or infer any medication details not explicitly stated. Any numbers under ten must be written as words except for measurements.) [Summary of findings on physical examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a paragraph of full sentences. Any numbers under ten must be written as words except for measurements.) [Summary of the management plan discussed with the patient, including any surgical details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a paragraph of full sentences. Any numbers under ten must be written as words except for measurements.) (Never invent or infer any patient details, assessment findings, plan items, interventions, or management steps. Use only the transcript, contextual notes or clinical note as the sole reference for all information included in this letter.) Yours sincerely, [Consulting clinician's full name and title] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.)