Dear Dr. Emily Carter,
Thank you for referring Sarah Jones who I saw today for a periodontal assessment. She reports improved gingival health and reduced bleeding on probing following scaling and root planing. Please find a report of my findings and recommendations below.
Medical History:
- No significant changes since the last referral.
Clinical Findings:
- Probing depths: 2-4mm throughout, with no sites exceeding 4mm.
- Bleeding on probing: Minimal, present at 2 sites.
- Clinical attachment loss: Stable.
- No radiographic evidence of progressive bone loss.
Diagnosis: Stable periodontitis, previously treated.
Impression: The patient demonstrates good oral hygiene and maintenance of periodontal health.
Treatment Plan:
1. Reinforce oral hygiene instructions.
2. Recommend supportive periodontal therapy every 6 months.
3. Patient will return if recommended by GDP or Dental Hygienist if there is concern over progressive disease.
Other recommendations: Continue regular dental check-ups and hygiene appointments with her general dentist.
Thank you for trusting Sarah Jones into my care. If you have any questions or concerns about anything in this letter, please do not hesitate to contact me. Once again, thank you so much for your referral.
Kind regards,
Dr. Thomas Kelly, Periodontist
[Contact Information, if necessary]
Dear [Referrer firstname],
Thank you for referring [Patient’s firstname] who I saw today for [reason for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). They report [patient reports outcome] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). Please find a report of my findings and recommendations below.
Medical History:
[list findings from medical history or say no change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Clinical Findings:
- [list findings from notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis: [diagnosis from notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression: [impression from notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment Plan:
- [list form with numbers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Include recommended recall interval for supportive periodontal therapy, add that the patient will return if recommended by GDP or Dental Hygienist if there is concern over progressive disease.)
Other recommendations: [follow-up recommended for the dentist or hygienist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you for trusting [Patient’s firstname] into my care. If you have any questions or concerns about anything in this letter, please do not hesitate to contact me. Once again, thank you so much for your referral.
Kind regards,
[Clinician's Name and Title]
[Contact Information, if necessary]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. 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. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; 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.)