General letter and notes

(Write the entire note in a collaborative tone, reflecting shared decision-making after a discussion of options. Avoid using definitive or unilateral terms like "I recommend." Do not describe lesions as "suspicious" or "concerning" unless these specific words are present in the transcript, contextual notes, or clinical note. When stating clinical diagnoses, avoid unequivocal language and instead use phrasing that reflects a clinical impression.) Diagnosis: [All diagnosed conditions and relevant findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not invent or infer a diagnosis, only include the clinician’s explicitly stated diagnoses. Write as a list.) Plan: [Detailed management plan including investigations, treatments, referrals and follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) [Details of how the patient attended the appointment, such as whether it was in person, via video call or by phone] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this line completely. Start with: “Thank you for …”) [Summary of the key discussions, history of the current issue, examination findings, diagnoses and next steps for the patient, using plain language and explaining any medical terms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Refer to the patient using "you." Write in paragraphs of full sentences with a good level of detail.) [Any leaflets given or to be sent to the patient, and confirmation that treatment options including no treatment were discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Whether a procedure is planned and that a link will be sent to a digital consent form] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If a procedure is planned, print: "A link will be sent to you with a digital consent form.") [Whether a further visit is planned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If a further visit is planned, print: "We have a plan as above and I look forward to seeing you then." If no future appointment is made, print: "We have not made any further appointments currently and I hope all goes well for you.") ”A detailed note of our conversation follows. Please do let me know if you have any further questions." Given to patient today: [Any items, information or prescriptions given to the patient during the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) Enclosures: [Any documents or materials enclosed with this letter, such as links to information leaflets or radiology or other reports] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.) ”Best wishes” [Clinician's name and initials] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) cc: “GP” [Whether the condition discussed is oral or dental in nature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If an oral or dental condition is present, print: "cc GDP".) Detailed Notes: (Include detailed key discussion points, history of the current issue, examination findings and decisions made. 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 included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, just 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. Refer to the patient as Pt.) Next Appointment Date: [Whether a second appointment date is planned and the date if confirmed] (Only include if a second date is planned as per the transcript, contextual notes or clinical note, else omit section entirely. If no date has been set, print: "Date TBC".) Removal of Sutures: [Whether removal of sutures will be required, and if so, when and by whom] (Only include if removal of sutures is mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Tasks for Office: (Always include the following information as a list.) [Instructions for office staff regarding patient notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) [Self pay fee or quotation details] (Only include if a self pay fee or quotation is mentioned in transcript, contextual notes or clinical note, else omit completely.) [Appointment booking instructions] (Only include if mentioned in transcript, contextual notes or clinical note, else omit completely.) [Theatre booking instructions] (Only include if mentioned in transcript, contextual notes or clinical note, else omit completely.) [Instructions to send drawings or photos] (Only include if mentioned in transcript, contextual notes or clinical note, else omit completely.) [Plan and codes, date of surgery, arrival time, operative slot length and venue for surgery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely. The default venue is Mount Alvernia Hospital. If minor ops is mentioned, the case will be done in minor ops. If the patient is having a general anaesthetic or intravenous sedation, the case will be in main theatre. All other cases will be in the day surgery unit.) FPP CN Fee £ [Fee amount] (Only include if a FPP CN fee is mentioned in transcript, contextual notes or clinical note, else omit completely. The number will be added manually.) [Type of review, whether video, phone call or face to face, and what investigation results are required at the review if any] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely. If surgery is taking place, this review will be with pathology results, unless the only surgery planned is removal of teeth or the surgery is arthrocentesis.) [Details of radiological, blood or microbiology tests planned, where they will be performed and any office actions required for forms or patient contact] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) [Whether a pathology form is needed] (Only include if a pathology form is mentioned in transcript, contextual notes or clinical note, else omit completely.) [Disposition of patient notes if the patient has been discharged] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.)