GP standard letter
(For NHS GP or other HCP)
Dear Doctor,
Your patient John Smith attended an appointment at our clinic. Please find below details of their consultation for your records:
Date of appointment: 01 November 2024
Time of appointment: 14:30
Type of consultation: New Patient Consultation
Doctor consulted: Dr. Anya Sharma
Confirm patient offered chaperone and identification checked, if not mentioned assume this is has been done and list as done: Chaperone offered and identification checked.
Diagnosis:
1. Suspected Stage II Invasive Ductal Carcinoma
Presenting complaint(s): Patient presents with a palpable lump in the left breast, discovered during self-examination. Patient reports no significant past medical history. Medications: None. Allergies: NKDA. Family history: Mother diagnosed with breast cancer at age 62. Social history: Non-smoker, occasional alcohol consumption.
(Relevant) Examination findings: BP: 130/80 mmHg, HR: 88 bpm, RR: 16, Sats: 98% on room air. Temp: 37.1°C. Height: 170cm, Weight: 70kg. Left breast exam reveals a 3cm firm, non-tender mass in the upper outer quadrant. No palpable axillary lymphadenopathy.
Investigations requested:
* Mammogram
* Ultrasound of left breast
* Core biopsy of breast mass
Medications prescribed: None
Medications recommended: None
Recommendations: Patient to undergo mammogram, ultrasound, and core biopsy. Results will be discussed at a follow-up appointment in two weeks. Safety netting advice given: If the patient experiences any bleeding from the nipple, significant increase in the size of the lump, or any new symptoms, they should seek immediate medical attention. If your symptoms get worse please consider whether you need to attend Teddington Walk in Hospital (minor issues) or your nearest A&E. We do not offer an out of hours service and will not respond to an email out of hours with medical queries
(Only include information if it is explicitly mentioned in the transcript, contextual notes or clinical note; if information is not mentioned, omit it completely and do not state it is missing.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information.)
Dear Doctor,
Your patient [PATIENT NAME] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) attended an appointment at our clinic. Please find below details of their consultation for your records:
Date of appointment:
[Date of appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Time of appointment:
[Time of appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Type of consultation:
[Type of consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Doctor consulted:
[Doctor consulted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Chaperone and Identification:
[Confirmation that chaperone was offered and identification checked] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis:
[List each diagnosis using the terms confirmed/presumed/suspected if explicitly mentioned. If not specified, list diagnoses in numerical order only if mentioned.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting complaint(s):
[Mention the patient's presenting complaints, relevant past medical history, medications with doses, allergies, family history of disease, and social history including alcohol and smoking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(Relevant) Examination findings:
[Pulse, BP, RR, sats, temp, height, weight, relevant physical findings, and any point of care test results such as urinalysis, peak flow, ECG, or pulmonary test results. List values where explicitly mentioned. If red flag symptoms are explicitly mentioned (bleeding, weight loss, lump, change in bowel habit, persistent cough, chest pain, haemoptysis, jaundice, persistent abdominal pain >6 weeks, or unusual pains), list these separately under "Red flag symptom identified" and note if referral for urgent suspected cancer (2-week rule) was made.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations requested:
[List blood tests or other investigations requested] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Medications prescribed:
[List prescribed medications with doses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Medications recommended:
[List recommended medications with doses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Recommendations:
[Outline the plan of treatment including any follow-up required. Include any explicitly mentioned safety netting advice, using specific terms such as when to seek help if symptoms worsen or temperature does not settle. Always include the following statement if present in the transcript:
"If your symptoms get worse please consider whether you need to attend Teddington Walk in Hospital (for minor issues) or your nearest A&E. We do not offer an out of hours service and will not respond to an email out of hours with medical queries."] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript or context, else omit section entirely. Never come up with your own patient details, diagnoses, plans, or safety advice—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
