Letter to GP

Date: [Insert date of report] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Dear Dr [Insert referring doctor surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), Re: [Insert patient name and surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) File: [Insert file number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thank you for the referral of [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). I saw [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) on the [Insert date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). [Insert patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) presented with [Insert medical complaints including reason for visit, symptoms, duration, aggravating factors, treatments performed, medications used, and conservative treatments used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical conditions include: [Insert list of medical conditions with ICD-10 codes in brackets] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medication used: [Insert medications used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social history: [Insert smoking and alcohol history with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [Insert allergies with ICD-10 codes in brackets] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical examination performed on [Insert date of service] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) showed [Insert clinical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Radiological investigations performed included: [Insert radiological investigations and findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The diagnosis of [Insert diagnosis with ICD-10 code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) was made, and the following treatment options were discussed: [Insert treatment options discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The decision was made to: [Insert treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) If you have any enquiries, please feel free to contact us. Once again, thank you for the referral. Kind regards, [Insert clinician title, name and surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert clinician specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert clinician registration numbers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript or contextual notes; otherwise omit the section entirely. Never come up with your own patient details, medical history, symptoms, diagnoses, examination findings, investigations, treatment options, or plans. Use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Add ICD-10 codes only when explicitly provided in the source material.)