General letter and notes

(Write the entire note in a collaborative tone, reflecting shared decision-making after a discussion of options. Avoid using definitive or unilateral terms like "I recommend". Do not describe lesions as "suspicious" or "concerning" unless these specific words are present in the transcript, contextual notes, or clinical note. When stating clinical diagnoses, avoid unequivocal language and instead use phrasing that reflects a clinical impression.) **Diagnosis:** [List all diagnosed conditions and relevant findings as stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as bullet points.) **Plan:** [Detailed management plan including investigations, treatments, referrals, and follow-up arrangements] (Do not include history and examination which should be in the body of the letter along with a detailed plan explanation. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) "Thank you for attending your appointment today" [state if in person, video call, or phone call if mentioned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.). [Summarise key discussions, diagnoses, and next steps for patient using plain language and explaining any medical terms, refer to patient using "you"] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [If procedure is planned, state what leaflets have been given if any and state that options were discussed including no treatment, state that a link will be sent to a digital consent form] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [State "We have a plan as above and I look forward to seeing you then" if further visit is planned, or state "We have not made any further appointments currently" if no future appointment is made] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "A detailed note of our conversation follows." "Please do let me know if you have any further questions." **Given to patient today:** [List any items, information, or prescriptions given to patient during consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Enclosures:** [List any documents or materials enclosed with this letter] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) Best wishes cc GP, [other individuals and their roles that need to be cc'd] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Detailed notes:** [Comprehensive detailed notes of consultation] (Refer to patient as Pt, not they or she or he. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs or bullet points as appropriate to capture all relevant information.) **Tasks for office:** [Instructions for office staff regarding notes] (State "Scan and shred notes" if patient has been discharged and has not had a cancerous lesion treated by the clinician, or "Keep notes" if there has been a cancer of any kind treated by the clinician or if another review is planned. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Self pay fee or quotation if mentioned, make appointment, book theatre, send drawing or photos] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Date of surgery, arrival time, operative slot time, venue for surgery] (Default venue will be Mount Alvernia Hospital, cases will be done in minor operations if minor operations is mentioned, or in main theatre if having general anaesthetic or intravenous sedation, all other cases will be in Day Surgery Unit. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Procedure codes] (Only include if surgery is planned. Use the following codes: 1st excision of malignant lesion head and neck S0602, 1st excision of malignant lesion trunk and limbs S0603, 2nd excision of malignant lesion head and neck S0604, 2nd excision of malignant lesion trunk and limbs S0605, excision of lesion of skin x3 head and neck S0632, excision of lesion of skin x3 trunk and limbs S0633, excision of lesion of skin 4 plus head and neck S0642, excision of lesion of skin 4 plus trunk and limbs S0643, removal of lipoma S0656, benign lesion head and neck not scalp S0654, benign lesion head and neck not scalp flap S0655, benign lesion trunk and limbs greater than 10 centimetres or scalp greater than 5 centimetres S0652, benign lesion trunk and limbs less than 10 centimetres or scalp less than 5 centimetres S0651, biopsy of skin S1500, shave biopsy of skin S1420, excision of pinna D0210, excision of lesion of lip F0200, excision lesion mouth F3810, biopsy of mouth lesion F4210, excision of lesion of palate F2810, excision of lesion tongue F2310, biopsy of salivary gland F4810, local flap less than 9 centimetres S2500, local flap more than 9 centimetres S2502, full thickness skin graft head and neck up to 9 centimetres S3624, full thickness skin graft trunk and limbs up to 9 centimetres S3622, full thickness skin graft head and neck additional 16 centimetres S3625, reconstruction of lip using skin flap F0420, coronectomy F0911, surgical removal of tooth or teeth F0950, surgical removal wisdom teeth F0910, examination or manipulation of joint under general anaesthetic with or without injection or arthrogram W9240. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) FPP CN Fee £ [fee] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Date of second surgery if planned, state date to be confirmed if no date set] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Removal of sutures required or not, if required mention when and by whom] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Type of review] (State if video, phone call, or face to face, state what results of investigations are required at review, if surgery taking place this review will be with pathology results unless only surgery planned is removal of teeth or surgery is arthrocentesis, if radiological investigation or blood test or microbiology test is planned state if has been done or where it will be done and if office needs to deal with any forms or be in touch with patient. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pathology form needed] (State no if not for surgery, state yes and for BALA if skin lesion to be operated on or for Di Palma if mouth or salivary gland. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Patient discharge status and notes management] (If patient is discharged state so and say what should happen to notes, if patient has had cancer of any kind notes should be kept, otherwise state notes to be scanned and shredded. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)