Pain Clinic Note

"Date of clinic:" [Date of clinic appointment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) Patient particulars: [Patient's full name] ([Patient's date of birth] (Use format DD/MM/YYYY.)) "NHS No." [Patient's NHS number] (Format as 000 000 0000. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Hospital No." [Patient's hospital number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Address:" [Patient's full address] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Insurer:" [Patient's insurer name or self-pay status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Letter to" [Recipient's title and full name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Copy to" [Names and roles of copy recipients] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Dear" [Recipient's title and surname] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "I reviewed" [Patient's first name] "in my clinic today" [Consultation type] (Only include consultation type if explicitly mentioned in transcript, contextual notes, or clinical note, else omit. If patient name not mentioned, use "the patient".) Review: [Narrative summary covering patient presentation, referral details, reason for visit, current condition, symptoms, progress since last review, discussion points, patient concerns, shared decision-making, explanations provided regarding diagnosis or management, relevant past medical history, and social history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a professional narrative in paragraphs of full sentences. Do not include examination findings in this section.) Examination: [Summary of physical examination findings including observations, vital signs, palpation findings, range of motion assessments, neurological tests, special tests, and other relevant examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Present as a single paragraph without line break after the heading.) Summary: - [Summary of relevant past and present history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) - [Summary of key examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) - [Summary of clinical impression] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) - [Summary of current medications and any medication-related issues] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) - [Summary of relevant surgical or procedural history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) - [Summary of investigation findings including imaging, blood tests, or other diagnostic results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in concise sentences.) [Clinical impression or overall summary of findings as stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) Diagnosis: 1. [Primary diagnosis] (Only include diagnoses if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 2. [Secondary diagnosis] (Only include diagnoses if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 3. [Additional diagnosis] (Only include diagnoses if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 4. [Additional diagnosis] (Only include diagnoses if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) Management Plan: 1. [First management plan item including medications, interventions, lifestyle advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 2. [Second management plan item] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 3. [Third management plan item] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 4. [Fourth management plan item] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 5. [Additional management plan items] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Many thanks" "Yours sincerely" [Clinician name and credentials] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else use clinician information from patient details.) [Clinician job title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Tasks: (Only include this entire section if tasks are explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) For Admin Team: [Tasks for administrative team including appointment bookings, letter distribution, scan requests, or other administrative actions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this subsection entirely. List as bullet points.) For Self: [Personal tasks or reminders for the clinician including follow-up actions, reviews, or clinical tasks] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this subsection entirely. List as bullet points.) Other Tasks: [Any other tasks not categorised above] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this subsection entirely. List as bullet points.)