Physician Template

Clinic Letter Learning Disability (Youth)

A professional Physician template for healthcare professionals.

About this template

Streamline your documentation for young patients with learning disabilities using our comprehensive clinic letter template. Specifically designed for paediatricians, psychiatrists, and other medical professionals, this template helps you capture essential developmental, social, educational, and psychiatric information. Efficiently record diagnoses like ADHD and autism spectrum disorder, medication details, and vital measurements. Our template ensures clear documentation of developmental history, family context, mental state examination findings, and robust risk assessments. Perfect for creating detailed psychiatric notes, Heidi, your AI medical scribe, can populate this template directly from your consultations, ensuring accuracy and consistency in every entry, helping you provide holistic care and improve patient outcomes.

Preview template

Clinician Specialty: Physician **Name:** Thomas Smith **Date of Birth:** 15/03/2010 **NHS Number:** 123 456 7890 **Date of appointment:** 01/11/2024 **Attendees:** * Sarah Smith (Mother) * David Smith (Father) * Dr. Eleanor Vance (Consultant Psychiatrist) **Diagnoses:** * **6A00.Z** Intellectual developmental disorder, global developmental delay, unspecified * **6A06.0** Attention deficit hyperactivity disorder, predominantly inattentive presentation * **6A02.2** Autism spectrum disorder with intellectual developmental disorder and with mild or no impairment of functional language **Current medication:** * Methylphenidate 10mg modified-release capsule, once daily in the morning. * Melatonin 2mg modified-release tablet, 30 minutes before bedtime. **Measurements:** Height: 145 cm Weight: 42 kg Heart Rate: 82 bpm BP: 110/70 mmHg Age-adjusted BMI: 19.9 (75th percentile) **Reason for appointment:** Thomas, a 14-year-old male with a diagnosis of global developmental delay, autism spectrum disorder, and ADHD, was brought in by his parents for a review of his current psychotropic medication and persistent difficulties with focus, impulsivity, and sleep. His parents also expressed concerns about escalating anxiety symptoms observed over the past three months, particularly in social settings and when facing unexpected changes to routine. **Developmental History:** Thomas had significant developmental delays, with independent walking achieved at 2 years and first words appearing around 3 years of age. He received early intervention services, including speech and language therapy and occupational therapy, from a young age. He was formally diagnosed with a moderate learning disability at 6 years old following a comprehensive cognitive assessment. Social reciprocity and communication difficulties have been evident since early childhood, consistent with his autism diagnosis. He has a history of sensory sensitivities, particularly to loud noises and certain textures. **Education History and Current Setting:** Thomas attends Willow Creek Special School, where he is in year 9. He receives significant one-to-one support in the classroom and follows a modified curriculum. He particularly struggles with literacy and numeracy but shows strong skills in visual arts and practical tasks. His teachers report difficulties with staying on task and occasional disruptive behaviours related to his ADHD. There are no vocational plans in place yet, but his parents hope for him to explore supported employment opportunities in the future. **Family and Social Context:** Thomas lives at home with both his parents, Sarah and David, and his younger sister, Emily (10 years old). The family dynamic is generally supportive, though parents report feeling overwhelmed at times by Thomas's needs. He has limited peer relationships outside of school and prefers solitary activities. His main social interactions occur within structured school settings or during family outings. There is no known family history of significant psychiatric illness. **Strengths and Difficulties:** Thomas's strengths include a keen interest in drawing and painting, a good sense of humour, and a generally compliant nature when routines are predictable. He enjoys spending time outdoors. Difficulties reported by parents include significant impulsivity, short attention span, and difficulty regulating emotions, often leading to meltdowns when frustrated or overstimulated. His anxiety manifests as repetitive questioning, avoidance of new situations, and increased irritability. **Mental State Examination (MSE):** Thomas presented as a pleasant young person, accompanied by both parents. He made limited eye contact, preferring to look at the floor or objects in the room. His speech was quiet, concrete, and sometimes fragmented, requiring prompts from his parents to elaborate. His mood appeared anxious, with occasional fidgeting and restless movements in his chair. He was able to attend to questions for short periods but easily distracted. No overt psychotic phenomena were observed. His thought content revolved around his school activities and concerns about upcoming changes to his school timetable. Insight into his difficulties was limited, consistent with his developmental stage and learning disability. **Physical Health:** Thomas's general physical health is good. He has no known chronic physical conditions. Sleep has been disrupted, with difficulty initiating sleep and occasional night-time awakenings, attributed to both his ADHD and anxiety. Appetite is generally good, though he can be particular about food textures. He maintains a regular bowel and bladder routine. There are no current physical health concerns requiring urgent attention. **Risk Assessment:** There is no evidence of active suicidal ideation or intent. Thomas has no history of self-harm. He does not pose a direct risk to others, although occasional outbursts of frustration can occur. Due to his learning disability and autism, he remains vulnerable to exploitation and bullying, particularly in less structured environments. His parents are vigilant in monitoring his safety and social interactions. **Impression:** Thomas is a 14-year-old male with a moderate learning disability, autism spectrum disorder, and ADHD. He presents with ongoing difficulties related to his neurodevelopmental conditions, exacerbated by emergent anxiety symptoms. His current challenges include attention and impulsivity difficulties, social communication impairments, and significant anxiety regarding routine changes and social interactions. These difficulties impact his functioning in both educational and home environments. **Plan:** 1. Continue current medication regimen (Methylphenidate 10mg MR daily, Melatonin 2mg MR nocte). 2. Increase Methylphenidate to 18mg MR daily for 2 weeks, then review its impact on focus and impulsivity. 3. Refer for an initial assessment with the Child and Adolescent Mental Health Services (CAMHS) for a comprehensive anxiety management programme, adapted for young people with learning disabilities. 4. Liaise with Willow Creek Special School to implement anxiety reduction strategies within the classroom setting and ensure consistent routines. 5. Advise parents on strategies to manage Thomas's anxiety at home, including visual schedules and social stories. 6. Schedule a follow-up appointment in 6 weeks to review medication efficacy and anxiety management progress. Yours sincerely, Dr. Thomas Kelly, Consultant Paediatrician Cc: Sarah Smith (Mother) for Thomas's school Ms. Eleanor Green, Social Worker, Local Authority Social Care Team

(This should be a psychiatric note for a young person with a learning disability. Focus on developmental, social, educational, and psychiatric aspects. Write in full sentences and paragraphs unless specified otherwise.) **Name:** [Patient's full name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Date of Birth:** [Patient's date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) **NHS Number:** [Patient's NHS number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Date of appointment:** [Date of appointment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) **Attendees:** [List of attendees and their relationship to patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List all individuals present at appointment and their relationship to patient. Write as brief list.) **Diagnoses:** [List of patient's current psychiatric and developmental diagnoses including learning disability] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. List as bullet points. For each diagnosis, start the line with the corresponding ICD-11 code in bold. Where available, include relevant ICD-11 extension codes.) **Current medication:** [Details of current psychotropic and other medications including dosage and frequency] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as structured list.) **Measurements:** Height: [Patient's height with units] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) Weight: [Patient's weight with units] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) Heart Rate: [Patient's heart rate with units] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) BP: [Patient's blood pressure reading] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) Age-adjusted BMI: [Age-adjusted BMI value and percentile] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.) **Reason for appointment:** [Summary of main reasons for psychiatric appointment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Developmental History:** [Details of patient's developmental milestones, delays, and relevant history from birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Education History and Current Setting:** [Details regarding patient's educational history, current school or college, level of support provided, and any vocational plans] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Family and Social Context:** [Description of patient's family composition, relationships, living situation, and social network] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Strengths and Difficulties:** [Summary of young person's strengths, interests, and reported difficulties in behaviour, emotions, and social interaction] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Mental State Examination (MSE):** [Observations of patient's presentation, behaviour, communication, mood, and other MSE findings, adapted for young person with learning disability] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Physical Health:** [Assessment of patient's general physical health including sleep, appetite, and any relevant physical conditions or concerns] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not include height, weight, or BP measurements if already documented in Measurements section. Write in paragraphs of full sentences.) **Risk Assessment:** [Assessment of current risks including to self, to others, and from others, considering vulnerabilities related to learning disability] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **Impression:** [Summary that synthesises all gathered information to explain young person's presentation and difficulties] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraphs of full sentences.) **Plan:** [Detailed plan for ongoing management including any medication changes, therapeutic interventions, referrals, and follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as numbered list.) "Yours sincerely, [Clinician name and professional role/speciality] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write each clinician on a new line if multiple present. Include supervisor clinicians.) Cc: [Patient's school via next of kin's name] (Only include if patient's school and next of kin are mentioned for correspondence in transcript, contextual notes, or clinical note, else omit completely.) [Social worker's name and details] (Only include if patient is under social care and social worker's details are mentioned in transcript, contextual notes, or clinical note, else omit completely.)

Browse more templates Use this template

How to use this template

Download the template

Get started by downloading the template to your device

Customize to your needs

Tailor the template to match your specific requirements

Deploy and share

Implement your customized template and share with your team

Browse more templates Use this template

Say hello to your AI medical scribe

Smarter notes, better care

Use this template

Specialty

Physician

Used

1 times

Type

Note

Last edited

2/16/2026

Created by

Jerry Chen

About this template

Preview template

Clinic Letter Learning Disability (Youth)

About this template

Preview template

How to use this template

Download the template

Customize to your needs

Deploy and share

Say hello to your AI medical scribe

Clinic Letter Learning Disability (Youth)

About this template

Preview template

How to use this template

Download the template

Customize to your needs

Deploy and share

Say hello to your AI medical scribe

Related Templates

Fam Med Office Visit Note

Ortho Office Note

Medical Assessment Form (PA 635)