Fit for Surgery Referral

Dear [Insert referring doctor’s name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thank you for seeing the patient below. Re: [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) File: [Insert file number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I am writing to refer my patient, [Insert patient full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), for an assessment to determine if they would be fit for the following surgery: [Describe the proposed surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) is known with [List medical conditions with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) and is currently using [List current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Surgical History: [List previous surgeries including year performed, surgeon, and hospital if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [List allergies with ICD-10 codes if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: [Describe relevant social history such as smoking status with ICD-10 code if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Alcohol History: [Describe alcohol use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The patient presented with the following complaint: [Describe history of presenting complaint, reason for visit, and issues discussed, including ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I am planning the following surgery: [Describe planned surgical intervention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) on [Insert planned date of surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Your expertise would be greatly appreciated in assisting with an evaluation and assessment to determine if [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) would be fit for the planned surgical intervention. Thank you for your assistance and attention to this matter. Yours sincerely, [Insert clinician title, name and surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert clinician type or specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, medical history, medications, social history, assessment, opinions, or plans. Use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Use as many lines or paragraphs as needed to accurately reflect the documented information.)