Subject: Referral of Ms. Sarah Jones
Dear Dr. Emily Carter,
1 November 2024
RE: Ms. Sarah Jones, DOB: 12/03/1985
Thank you for seeing Ms. Jones, who I am referring for chronic lower back pain and consideration for acupuncture treatment.
History:
Ms. Jones presents with a 6-month history of lower back pain, described as a dull ache that radiates to her left buttock. The pain is worse after prolonged sitting and standing, and is relieved by rest. She denies any history of trauma. Associated symptoms include occasional stiffness in the morning.
Medications:
Ms. Jones is currently taking ibuprofen 400mg as needed for pain relief.
Investigations:
No investigations have been performed to date.
Management to date:
Ms. Jones has tried over-the-counter pain relievers and has been using a heat pack for symptomatic relief. She has not had any formal physical therapy or other interventions.
Reason for referral/Specific questions:
I am referring Ms. Jones for an acupuncture consultation to explore the potential benefits of acupuncture for her chronic lower back pain. I would appreciate your assessment and recommendations for a treatment plan.
Thank you for your assistance with this patient.
Yours sincerely,
Dr. Michael Brown
Acupuncturist
Brown Acupuncture Clinic
020 7123 4567
drmichaelbrown@email.com
Subject: Referral of [patient's full name, including title if applicable]
Dear [name and title of referring doctor/specialist],
[date of referral]
RE: [patient's full name and date of birth]
Thank you for seeing [patient's full name], who I am referring for [reason for referral, including the specific medical condition or issue requiring specialist attention]. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
History:
[detailed chronological history of the patient's presenting complaint, including onset, duration, character, aggravating and relieving factors, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[relevant past medical history, including significant illnesses, hospitalizations, and surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[social history, including occupation, living situation, smoking status, alcohol consumption, and recreational drug use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[family history of relevant medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications:
[list of all current medications, including dosage, frequency, and route of administration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[known drug allergies and reactions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations:
[summary of relevant investigations performed, including laboratory results, imaging findings, and other diagnostic test results, with dates if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Management to date:
[description of treatments or interventions already attempted, including their effectiveness and any adverse effects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Reason for referral/Specific questions:
[clear and concise reason for the referral, outlining the specific questions or concerns that require specialist opinion or intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Thank you for your assistance with this patient.
Yours sincerely,
[referring doctor's full name]
[referring doctor's professional title]
[referring doctor's practice name]
[referring doctor's contact details, including phone number and email]
(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, 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.)