Sleep Letter

Many thanks for the referral of [Insert patient full name]. [Insert patient full name] has been seen today in my Sleep clinic today. **History: ** Snoring and apnoeas: [describe patient-reported snoring, witnessed apnoeas, frequency, severity, impact on bed partner, historical duration, and any changes over time] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Sleep pattern: [describe sleep-wake cycle including bedtime, sleep onset latency, wake after sleep onset, final wake time, total sleep time, variability in routine, and any shift work or jet lag] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Sleepiness and fatigue: [describe symptoms of excessive daytime sleepiness, fatigue, impact on daily functioning, napping, and any sleep attacks or microsleeps] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Sleep hygiene: [describe routines and behaviours around bedtime, caffeine or stimulant use, screen exposure, noise/light disturbances, and overall sleep environment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Restless leg: [describe symptoms consistent with restless legs syndrome including urge to move legs, discomfort at rest, timing of symptoms, and relief with movement] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Sleep related behavioral history: [describe any parasomnias, sleepwalking, acting out dreams, sleep talking, nocturnal enuresis, or unusual behaviours during sleep] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Neurocognitive symptoms: [describe issues such as memory problems, concentration difficulties, mood disturbances, irritability, or other cognitive complaints related to sleep disturbance] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Medical history: [document relevant past medical conditions including respiratory, neurological, psychiatric, metabolic, and cardiovascular history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Personal habit: [describe lifestyle factors such as smoking, alcohol, recreational drug use, exercise habits, and dietary factors relevant to sleep] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Examination: [Full name] is [describe findings from general and focused examination including BMI, neck circumference, ENT findings, craniofacial features, cardiovascular or neurological signs] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Polysomnogram: [document results of sleep study including AHI, oxygen saturation trends, sleep architecture, arousals, limb movements, and any technical limitations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Assessment: [summarise diagnostic impression including suspected or confirmed sleep disorders, relevant contributing factors, and clinical rationale] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Plan: [outline management plan including further investigations, treatment options, follow-up arrangements, education provided, and referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs 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 include 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.)