Speciality Referral

**Consultation with Specialist:** [document the date and time of the consultation, the name and role of the specialist being consulted, and the patient's identifying information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentence.) **Reason for Consultation:** [describe the primary reason for initiating the consultation with the specialist, including the patient's current presentation, symptoms, and the specific clinical question or dilemma for which specialist input is sought] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) **Patient Presentation and History:** [detail the patient's relevant medical history, including past medical conditions, significant co-morbidities, current medications, allergies, social history pertinent to the presentation, and any recent changes in their condition leading to the consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph form using clinical abbreviations e.g. T2DM, CKD, AF, HTN, BPH.) **Clinical Findings:** [summarize pertinent clinical findings from physical examination, including vital signs, general appearance, and system-specific findings relevant to the consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief sentences using medical acronyms. Do not include units for vital signs or investigations.) **Investigations and Results:** [document relevant investigation results, including blood work, imaging studies (radiological findings), and any other diagnostic tests performed. Specify abnormal findings and their significance to the patient's condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use medical abbreviations and exclude units. Write in short bullet points using "-".) **Discussion with Specialist:** [provide a detailed account of the back-and-forth discussion with the specialist, including specific questions asked, the specialist's initial thoughts or differential diagnoses, and any concerns raised by either party. Document the areas of agreement and disagreement in the clinical assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) **Shared Decision Making and Plan:** [outline the shared decision-making process, detailing the agreed-upon management plan, including further investigations, treatment modifications, or interventional procedures. Specify roles and responsibilities for ongoing care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) **Consideration for Takeover of Care:** [document the discussion regarding the possibility of the specialist team taking over the patient's care. Include the specialist's perspective on the appropriateness of transfer, any criteria for transfer, and reasons for accepting or declining the takeover of care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) **Specialist Concerns/Recommendations:** [if the specialist does not agree to take over care, detail their specific concerns, reasons for declining, and any alternative recommendations or advice provided for ongoing management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) **Further Actions/Follow-up:** [describe any immediate actions to be taken following the consultation and the plan for ongoing follow-up, including who will be responsible for what aspects of care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Also try to use medical and investigations acronym where possible throughout the consultation. Avoid writing investigations and vitals units, write only numbers.)