Hospital Medical Release Notes

- Patient full name: [insert patient full name] (Insert the full legal name of the individual authorising the release of records; only include if explicitly mentioned in the transcript, contextual notes or clinical note) - Date of birth: [insert patient date of birth] (Enter the full date of birth using standard format; only include if stated) - Medical record number or ID: [insert patient medical ID] (Include only if the medical record number is explicitly provided) - Facility name: [insert name of hospital or facility where the patient was treated] (Enter the full name of the hospital or facility involved in the admission; only include if mentioned) - Facility address and contact: [insert facility address and phone number] (Write the full mailing address and contact number of the hospital or facility on one line; include only if stated) - Date of treatment: [insert treatment date or admission range] (Enter the exact date or date range during which the hospitalisation or treatment occurred; only include if explicitly mentioned) - Recipient – name: [insert name of individual or organization to receive the records] (Enter the name of the individual or entity authorised to receive the patient’s records; only include if stated) - Recipient – relationship to patient: [insert relationship of recipient to patient] (Write the described relationship, such as caregiver, attorney, or family member; include only if mentioned) - Recipient – address/contact: [insert recipient address and phone number] (Write the recipient's full mailing address and contact details on one line; include only if stated) - Purpose of disclosure: [insert reason for the medical information disclosure] (Write a paragraph in full sentences explaining the reason the patient has given for the information release; only include if mentioned. Include any reason such as legal, clinical, personal use, or at the request of the patient — but only if specifically stated in those terms) - Types of records to be released: [insert types of records the patient authorizes to be disclosed] (Write in full sentences or as a continuous line the specific types of records selected for disclosure — e.g., admission notes, operative notes, discharge summaries. Do not summarise or assume any types; only include those explicitly selected or mentioned) - Information to be excluded (if any): [insert any record types or content categories the patient wishes to exclude from the disclosure] (State which specific types of information the patient has chosen to exclude from the release, such as mental health or HIV-related records; include only if exclusions are explicitly stated) - Format of disclosure: [insert format in which records should be released] (Indicate how the patient has requested the records to be shared — e.g. printed, electronic, via secure portal; write as a single line or short sentence; include only if specified) - Disclosure expiration: [insert expiration date or event] (State when the authorisation expires — this may be a specific date, event, or condition like “until revoked”; include only if a timeframe has been provided) - Patient rights and revocation clause: [insert acknowledgement of rights and revocation instructions] (Write a paragraph in full sentences detailing the patient's right to revoke this authorisation, the process for doing so, and any limitations on revocation. Include only if such statements have been explicitly included) - Signature of patient: [insert signature of patient] (Include only if the patient has signed the authorisation) - Date of signature: [insert date of signature] (Write the full date the patient signed the form; only include if provided) - Printed name of patient: [insert printed name of patient] (Include only if a separate printed name is recorded in addition to the signature) - Name of authorized representative (if not the patient): [insert name of proxy signer] (Only include if someone other than the patient is legally authorised and has signed on their behalf) - Legal authority of authorized representative: [insert basis of legal authority] (State the legal basis under which the person is signing — e.g. parent, guardian, power of attorney — only if explicitly stated) - Interpreter name (if applicable): [insert name of interpreter] (Include only if interpreter or translator was used and named) - Interpreter signature (if applicable): [insert interpreter's signature] (Include only if an interpreter signed the form) (Never come up with your own patient details, record types, release formats, purposes, or legal authority — 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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Maintain all formatting and paragraph structure exactly as described in the example note.)