Paed Letter - Initial (Medical)

[Today's Date] (Formatted as Day Worded Month Year) [Referring Clinician's Name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Referring Clinician's Practice Address] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [City, State, Zip Code] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Dear Dr [Referring Clinician’s Name] (Only include if explicitly mentioned in transcript or context, else omit section entirely.), Re: [Patient’s Full Name in format: Firstname SURNAME] DOB: [Patient’s Date of Birth] (Include age in years and months) Address: [Patient’s Address] Section: Issues [numbered list of diagnoses or clinical issues. Use full name of diagnoses initially, followed by the abbreviation in brackets] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Section: Medications [dot-point list of all current medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Section: Services [dot-point list of clinicians or services currently involved in care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Section: Growth Parameters - Weight: [Weight measurement and centile] - Height: [Height measurement and centile] - Head Circumference: [Head circumference measurement and centile] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Section: Consultation Summary "Thank you for referring [Patient’s First Name] for [reason for referral]. I had the pleasure of reviewing [him/her/they], along with [list of family members present], in my paediatric clinic today." [Summarise concerns relating to the referral reason including symptoms, investigations, prior treatments, and planned follow up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Summarise any additional unrelated concerns discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Summarise background medical history including diagnoses, previous surgeries, treatments, medications, immunisation status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Summarise relevant social history including family structure, household setup, schooling, and family history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Summarise dietary intake and appetite patterns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Summarise sleep patterns or issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Physical Examination [Summarise key physical findings, including blood pressure] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Do not include height and weight here. Write in paragraph format.) Section: Discussion with Family [Summarise discussion with parent/carer regarding diagnosis, management, medications or options provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Recommendations [numbered list of key points in the management plan, using brief summary statements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use as many points as needed. Final point must always address follow-up timing with self.) - However, if there are any more concerns in the meantime, then I am happy to see [Patient’s First Name] sooner. "Should you have any further questions regarding [Patient’s First Name], please do not hesitate to contact me." (Never come up with your own 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 include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)