Letters to GP

Dear [GP's first name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise write “Colleague”), It was my pleasure assessing [Patient's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank) in my clinic on [Date of visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise write “today”). Diagnosis: [Insert diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank.) Management: [Insert paragraph summary of the management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write as a bullet point summary.) [Describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Describe past medical history, including relevant previous surgeries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Mention medications and herbal supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Describe social history including occupation, living situation, smoking or alcohol use, etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Mention any allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) During the consultation, the following findings were noted: [Describe physical examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Mention any diagnostic tests performed and their results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) Based on the above findings, I have proposed the following management plan for [Patient's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank): [Describe treatment plan, medications prescribed, and lifestyle recommendations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) [Mention any referrals to specialists or further investigations required] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank. Write in paragraph format.) Thank you for the opportunity to care for [Patient's first name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank) and for your kind referral. Yours sincerely, Electronically sighted and approved by the author prior to dispatch. [Clinician title and full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank.) [Clinician qualifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank.) [Clinician specialty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank.) [Your contact information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or support strategies – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. Only include a placeholder if it has been explicitly mentioned in the transcript or context — otherwise omit the section completely. Always write numbers (e.g. dates, values) in digits, not words. Use paragraph format as instructed for each section.)