Dear Mrs. Evelyn Davies,
It was a pleasure to see you today and review your health concerns. I truly appreciate the time you took to share details about your health and personal life. I enjoyed hearing about your recent trip to the Lake District.
1. We discussed your persistent cough. This has been ongoing for three weeks and is worse at night. I explained that it could be due to a viral infection or, less likely, a bacterial infection. We discussed the possibility of a chest infection. I recommended rest, fluids, and over-the-counter cough medicine. I also advised you to monitor your temperature and any changes in your breathing. If your symptoms worsen, please contact the surgery for a review.
2. We also talked about your concerns regarding your blood pressure. Your readings today were slightly elevated. I explained the importance of managing blood pressure to reduce the risk of heart disease and stroke. I advised you to continue taking your prescribed medication and to monitor your blood pressure at home twice a day and record the readings. We will review these readings at your next appointment.
3. We discussed your recent blood test results. Your cholesterol levels are slightly elevated. I recommended dietary changes, including reducing saturated fats and increasing fibre intake. I also suggested increasing your exercise to at least 30 minutes of moderate-intensity activity most days of the week. We will recheck your cholesterol levels in three months.
Next Steps:
* Continue taking your prescribed blood pressure medication.
* Monitor your blood pressure at home and record the readings.
* Implement dietary changes and increase exercise.
* Schedule a follow-up appointment in three months to review your blood pressure and cholesterol levels.
Thank you for trusting me with your care. If you have any questions or concerns about anything we discussed, please do not hesitate to reach out.
Warm regards,
Dr. Thomas Kelly, General Practitioner
[Insert practice contact information]
Dear [insert patient’s name],
It was a pleasure to see you today and review your health concerns. I truly appreciate the time you took to share details about your health and personal life. [insert small talk or personal note relevant to the visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) I’ve summarized our discussion below to ensure you have a clear understanding of what we talked about during your visit.
1. [describe first topic or issue discussed, including explanation of condition or symptom in layperson's terms, actions discussed, key information to remember, and any treatments or monitoring plans] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
2. [describe second topic or issue discussed, including explanation in simple language, symptoms or improvements to monitor, treatments, advice or follow-up actions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
3. [describe third topic or issue discussed, with any recommendations, plans or actions required to address it] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[additional topics/issues discussed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Next Steps:
[summarise specific next actions for the patient, such as scheduling follow-ups, starting medications, monitoring symptoms or making lifestyle changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Thank you for trusting me with your care. If you have any questions or concerns about anything we discussed, please do not hesitate to reach out.
Warm regards,
[insert clinician’s name and title] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[insert clinician’s contact information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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.)