Gastroenterology Clinical Letter

[Instructions for letter preparation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Format in italics.) **Patient Name:** [Patient name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.) **Hospital Number:** [Hospital number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.) **NHS Number:** [NHS number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.) **Date of Birth:** [Date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.) [Referral source and brief reason for referral] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Specific instructions such as copying diagnosis from previous letter] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **[Type of encounter such as face to face or telephone, and whether it is a follow-up appointment]** (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Write exactly as dictated.) **Height:** [Height] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Weight:** [Weight] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **BMI:** [Body mass index] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Reason for Referral:** [Reason for referral] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list.) **Diagnosis:** [Diagnosis or problem] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Write exactly as dictated. Do not invent or infer a diagnosis.) **Problem:** [Problem or chief complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Write exactly as dictated.) **Surgical Details:** [Surgical details and history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list.) **Other Details:** [Other relevant medical details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list.) **Medications:** [Current medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write exactly as dictated.) **Allergies:** [Allergies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write exactly as dictated.) **Past Medical History:** [Past medical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write exactly as dictated. Do not invent or infer a diagnosis.) **Family History:** [Family history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write exactly as dictated.) **Suspected impression:** [Suspected impression or differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list. Do not invent or infer a diagnosis.) **Current symptoms:** [Current symptoms and patient's status since last review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list.) **Advice to GP:** [Advice to general practitioner regarding medication or management] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in the same order as mentioned in transcript.) [Main body of letter from dictation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences. Always place this section after the headings above.) "Yours sincerely" [Repeat all sections above if the dictation moves on to another patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)