GP Medical Update

Date: [Date of report] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Dear Dr [Surname of recipient], (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Re: [Patient name and surname] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Date of Birth: [Date of birth and calculated age in years] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) File: [File number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Opening acknowledgement of the referral including the patient's name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Begin with "Thank you for the referral of" and write in full sentences.) [Date of consultation and summary of medical complaints including reason for visit, symptoms, duration, aggravating factors, prior treatments, prior medications, and conservative treatments used] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Begin with "I saw [patient name] on the" and write in full sentences.) Medical Conditions: [List of medical conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a list.) Surgical History: [List of previous surgical procedures] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a list.) Medication Used: [List of current medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "None".) Social History: [Summary of smoking and alcohol history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "None".) Allergy: [List of known allergies and associated reactions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a list.) [Clinical examination findings from the date of service] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Begin with "Clinical examination that was performed on [date of service] showed" and write in full sentences.) [Radiological investigations performed and their findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Begin with "Radiological investigations performed included" and write in full sentences.) [Diagnosis made and treatment options discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Begin with "The diagnosis of" and write in full sentences.) [Treatment plan decided upon] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Begin with "The decision was made to" and write in full sentences.) "If you have any enquiries, please feel free to contact us." "Once again thank you for the referral." "Kind regards" [Clinician full name and title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Clinician specialty] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Clinician qualifications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Clinician medical practice number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Clinician practice registration number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)