Urology UK First Visit

DIAGNOSIS: [description of the clinician’s working or confirmed diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) PAST MEDICAL HISTORY: - [description of a medical condition or ailment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [description of a second medical condition or ailment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [description of any other pertinent past medical history not previously listed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PLAN: - [description of the first point in the patient's care plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [description of the second point in the patient's care plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [description of the third point in the patient's care plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) GP Action: - [description of what the GP needs to prescribe or do for the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) BODY OF LETTER: (Do not use bullet points in the body of the letter.) "I was pleased to review" [patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), "a" [patient's chronological age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "-year-old" [patient's gender] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), "today with regard to" [description of the patient's primary reason for the visit or chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "has a past medical history significant for" [summary of relevant past medical history or significant medical events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). "He/She presented with" [summary of the presenting complaint and relevant history, including onset, duration, severity, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). "On examination," [description of all relevant examination findings, such as physical characteristics, palpation results, and systemic examination details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). "There were no signs of" [description of any negative findings related to infection, abscess, or other specific concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). "My impression is that this is" [description of the clinical diagnosis or impression formed based on the patient's presentation and examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.). [description of the investigation or treatment decided upon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [description of advice given for safety-netting the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "I answered all of their questions and concerns and the patient was happy with the plan above." "Yours sincerely," [clinician's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [clinician's role or position] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)