New Patient - Letter [Orthopaedic Surgeon]

Diagnosis: - [Primary diagnosis including affected side] (List only the main diagnosis with affected side. If there are two distinct pathologies, include both, otherwise focus on the primary condition) Plan: - [Management plan item 1] (Each management plan item should be on its own line with a dash) - [Management plan item 2] - [Management plan item 3] Thank you for referring [patient full name] who I reviewed today. [patient first name] is a [patient age] year old [occupation] [sex] who presents with [chief complaint]. (Include occupation only if explicitly mentioned in the transcript; otherwise omit this term without noting its absence) [detailed history including onset, duration, severity, aggravating/alleviating factors, associated symptoms, functional limitations, previous injuries or trauma, treatments tried and responses. If patient has explicitly denied a therapy when asked about it, state this explicitly, e.g., "She has not tried physiotherapy"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [combined paragraph incorporating social history, medical and surgical history, current medications, and allergies. Include occupation, home supports, living situation, physical activities or hobbies if mentioned. Write as one cohesive paragraph with no headings or breaks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [Physical examination findings including inspection, palpation, range of motion, strength testing, joint stability, deformity, swelling, or tenderness. Then summarise investigations performed, including type (e.g. X-ray, CT, US, MRI), date (month/year), imaging provider name if stated, and key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [Summary of treatment discussion including explanation of diagnosis, education, treatment options discussed (surgical and/or non-operative), informed consent, patient resources provided, risks discussed, and any specific concerns addressed during the consult] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Thank you for your ongoing care of [patient_name]. Please feel free to get in touch if you have any questions or require further information regarding the management plan. Yours Sincerely, (Never come up with your own patient details, assessment, plan, interventions, evaluation, or discussion. Use only the transcript, contextual notes or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned, omit the placeholder completely without noting its absence. Write in full sentences with no section headings except for "Diagnosis:" and "Plan:" at the beginning. Format all diagnosis and plan items on separate lines with a dash. For dates, use month/year format. For imaging providers, include the name exactly as mentioned.)