[Date] 1 November 2024
Dr. Eleanor Vance
Urology Clinic
123 Harley Street
London, SW1A 1AA
Re: John Smith - Follow-up consultation
Dear Dr. Vance,
I touched base with John Smith through a video telehealth consultation today.
Brief summary of healthcare encounter: Mr. Smith presented for a follow-up consultation regarding his ongoing urinary retention issues. He reported some improvement with the medication, Tamsulosin, but still experiences occasional difficulty initiating urination and nocturia. He denies any new symptoms.
Plan:
- Continue Tamsulosin 0.4mg daily.
- Schedule a repeat uroflowmetry test in 3 months.
- Discussed lifestyle modifications, including fluid management and bladder training.
Closing statement: Please do not hesitate to contact me if you have any questions.
Your sincerely,
Dr. Thomas Kelly
Consultant Urologist
1234567
020 7123 4567
[Date]
[Referring Clinician's Name] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
[Referring Clinician's Practice Address] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
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Re: [Patient's Name] - [Reason for referral] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
Dear [Referring Clinician's Name], (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
I touched base with [Patient's Name] through a video telehealth consultation today.
[Brief summary of healthcare encounter] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
Plan:
- [First key point of plan] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
- [Second key point of plan] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
- [Third key point of plan] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
[Closing statement]
Your sincerely,
[Clinician's Name] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
[Qualification] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
[Registration Number] (include only if explicitly mentioned in the transcript, context or clinical note, else omit completely)
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(Never come up with your own referring clinician details, 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 to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, just leave the relevant placeholder or section blank.)