SOAP with GP Letter

**Subjective:** [List reasons for visit, including patient requests, symptoms, or concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Mention duration, timing, location, quality, severity, and contextual details of the primary complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Mention factors that worsen or alleviate the symptoms, including any self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Describe how the symptoms have progressed or changed over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Detail any previous similar episodes, including timing, management, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Explain how the symptoms have impacted the patient's daily life, work, and routine activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) [Mention any associated symptoms, both localised and systemic, relevant to the presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph form.) **Past Medical History:** [Mention past medical and surgical history, investigations, or treatments that contribute to or contextualise the current presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [Mention any relevant social history including lifestyle, occupation, habits, or social supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [Mention relevant family medical history that may have bearing on the presenting issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [Mention any environmental, occupational, or travel-related exposures that may relate to the presenting concern] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [Mention immunisation history or current vaccination status relevant to the current concern or general health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [Mention any other relevant subjective background information not captured above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph or list.) **Examination:** (Do not include any examination findings mentioned in the contextual notes and not mentioned in the current examination.) - [Vital signs measured during current examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [General appearance including level of distress, alertness, or other general observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Inspection findings including swelling, asymmetry, discolouration, or structural changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Palpation findings such as tenderness, masses, or lymphadenopathy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Otoscopy findings including description of external auditory canal and tympanic membrane] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Nasal examination findings including septum, turbinates, and mucosa appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Oral cavity and oropharynx findings including mucosa, tonsils, and dentition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Flexible nasendoscopy findings, including vocal cords, larynx, nasal cavity] (Only include if performed and explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Hearing assessment results including tuning fork or tympanometry if performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) - [Other relevant examination findings specific to the specialty or presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point.) **Assessment:** [1. Issue, problem or request 1 – list the name of the condition, concern or request only] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as numbered list.) [2. Issue, problem or request 2 – list the name of the condition, concern or request only] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as numbered list.) [3. Issue, problem or request 3 and onwards – list the name of the condition, concern or request only] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as numbered list.) **Plan:** [List treatments or interventions discussed and planned, including prescriptions, therapies, or procedures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [List investigations arranged or planned, including bloods, imaging, or functional studies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [List referrals made or planned, including the specialty and reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as list.) *** [Repeat the above information as a paragraphed, detailed GP feedback letter here. Thank the GP for the referral and go straight into the presenting problem in the same sentence. Write it using full sentences and appropriate grammar. Begin with a paragraph on history, followed by paragraphs on past medical history, examination and any special investigations, then conclude with the plan.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as formal referral reply letter with paragraph structure.) (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.)