General Letter and Notes

(Refer to patient as Pt, not they or she or he.) Diagnosis: - [Diagnosed conditions and relevant findings as explicitly stated by a clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not infer or assume a diagnosis.) Plan: - [Management plan including investigations, treatments, referrals and follow-up arrangements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; do not include history or examination; otherwise omit completely.) Thank you for attending your appointment today [describe consultation format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of key discussions, diagnoses and next steps written in plain language and explaining medical terms, referring to the patient as “you.”] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Statements related to procedures planned, information leaflets provided, discussion of options including no treatment, and mention of digital consent form] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Statements regarding future appointments or absence thereof] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) A detailed note of our conversation follows. "Please do let me know if you have any further questions." Given to patient today: - [Items, information or prescriptions given to the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Enclosures: - [Documents or materials enclosed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Best wishes cc GP cc GDP (Only include if related to an oral or dental condition and explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Detailed notes. **Tasks for Office:** - [Instructions for office staff regarding document handling or administrative actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (if surgery is planned, use a code from below and place in this section.) Procedure codes: [Procedure codes and descriptions relevant to planned surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [If a second date is planned, mention this and give the date if planned. If no date set, state date TBC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Removal of sutures: [Whether removal of sutures will be required, and when and by whom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Tasks for Office. (Always include the following information in a list.) [Date of surgery arrival time, operative slot time, venue for surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Fee information, review type, required investigation results, and administrative tasks associated with investigations or tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Pathology form requirements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Discharge status and instructions for handling notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)