Paediatric Review Letter

**"Our Ref:"** [Reference number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Clinic Letter [Date of letter] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) [Date of review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) [Patient name and address] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Sender's details [Hospital name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Department name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Address line 1] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Address line 2] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [City and postcode] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Telephone: [Contact telephone number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Department email: [Department email address] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Re: [Patient name, date of birth, and NHS number]** (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Dear [Patient name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Diagnosis:** [The clinician's stated ICD-10 diagnosis and code with summary of how patient meets criteria specifically, or primary symptoms, or brief formulation based on discussion] (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 structured paragraph.) [The clinician's stated comorbid diagnoses, health conditions, and relevant phenomena] (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 brief list.) [The clinician's stated differential diagnosis if under consideration, and whether this changes the physical risk discussed below] (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 brief statement.) **Plan agreed at the review:** [Date of plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) [Who was present in discussion] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief list.) [Brief one-line summary and overview plan without detail] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief statement.) [Action points for specific individuals with direct actions required] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Highlight with "Action For" prefix identifying the person or role. Write as brief bullet points.) **Medical risks of [high or low] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) weight for height and unhealthy weight [loss or gain] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.):** **Over time, being [high or low] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) weight for height can lead to numerous serious health consequences, rapid unhealthy weight [loss or gain] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) can also lead to serious medical complications:** [List of medical risks for this patient discussed in session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List with highest risk and most prevalent for this patient first. Write as bullet points.) **Bloods:** [Detailed summary of blood results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List with most recent blood results first. Highlight abnormal blood results. Indicate whether these have further health impact/implications discussed in review. Write as structured list.) **Interventions:** [Interventions, outcomes, and implications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as structured bullet points.) **Medications and Nutritional supplements:** [List of all medications and nutritional supplements currently taking including dosages] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as detailed list.) [Detailed summary of changes to medication and treatment plan over precise timeline detailing who will follow up and when, what to do in various possible outcomes, and how change will be assessed at next review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as structured paragraph with clear timeline.) [List of any recommended medical interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) Age: [Patient's age in years and months] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Height: [Height in metres and percentile reference] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Include relevant information if patient's height is stunted or impacted by their presentation.) [Mid parental centiles] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Include whether patient is in line with mid parental centiles or not.) [Weight and BMI centiles and percentiles objectively reported] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Median percentage weight for height reported with impact/context included] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Physiology:** [Physical observations undertaken in review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Highlight what these would score on MEED risk assessment. Present as list with highest risk items reported first. Write as structured list.) **Discussion** [Thorough and detailed discussion written in second person] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write using second person addressing patient directly. Write summary in distinct sections focussed on parts of review and physical symptoms. Order sections by MEED risk assessment priority and severity. Write in detailed paragraphs of full sentences.) **Impression:** [Clinical and medical impression of patient's condition] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Include impact of diagnosis and presenting problem with understanding of why problem is continuing. Write in second person addressing patient directly. Write as detailed paragraph in full sentences.) **Plan:** [Clear and detailed plan including action points and rationale for action points] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Include current MEED rating and evidence for this. Include safety netting advice in bold. Complete in second person addressing patient directly. Write as structured paragraph with bullet points for action items.) **Next review:** [Date of next review and details of who will attend] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) We agreed the plan as at the top of the letter. Yours sincerely, **_electronically checked and signed_** **_(Delegated signatory for [Consultant name]) (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)_** Signed By [Signatory name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Consultant name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Consultant title and role] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Hospital/department name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Service/team name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) CC Copies to: [List of recipients including GP and other involved doctors and clinicians] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief list.)