Patient Explainer Letter (FUSION SURGERY)

Dear [Patient Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), [Patient ID] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) It was a pleasure to see you today and review your health concerns. I appreciate the time you took to share details about your health and personal life. Thank you for consenting to an AI assistant transcribing during your consultation. [Insert small talk relevant to the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I’ve summarised our discussion below to ensure you have a clear understanding of what we talked about during your visit. Imaging available at [describe where the imaging is available (e.g., PACS system, patient-provided disk, or other)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 1. [Topic/Issue #1: Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) During our discussion, we talked about [describe the first topic/issue in simple terms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). This means [explain the condition, symptom, or topic in layperson's terms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). It is important to [describe any actions, reasons for concern, or key details to remember] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [If applicable, mention treatments, lifestyle adjustments, or monitoring required.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [Topic/Issue #2: Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Another key point we covered was [describe the second topic/issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). This relates to [explain in simple language] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). You may notice [describe symptoms or improvements to monitor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) and should consider [mention treatments, advice, or follow-ups if relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). 3. [Topic/Issue #3: Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) We also discussed [describe the third topic/issue, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). To address this, [lay out the plan or approach discussed, with clear explanations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [Include any specific recommendations for actions or observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. [Topic/Issue #4: Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) We described in detail the proposed surgical procedure [describe the surgical procedure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). We discussed in detail the expectations [describe the expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [State that in general the procedure is expected to improve the condition significantly, but we cannot guarantee full improvement or complete resolution of symptoms.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) We also discussed the potential risks of complications [list the possible complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [In general, spinal procedures may have the following complications: infection; bleeding; CSF leak with headaches, nausea, and vomiting; nerve damage with weakness, numbness, sensory loss, bowel and bladder control problems, and sexual problems; pain flare-up; partial or no improvement; need for further procedures; in very rare occasions paralysis, incontinence, and impotence; general complications such as DVT, PE, MI, stroke, blood pressure and blood sugar derangement; fatal outcome; allergy; and other very rare complications not mentioned here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [For lumbar fusion surgery specifically, potential risks may include abdominal organ damage and major abdominal bleeding, implant failure, implant malposition, adjacent segment degeneration, and the need for further surgeries.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [At the end of the consultation, the patient confirmed understanding of the proposed treatment plan, expectations, potential complications, and had no further questions. The patient was satisfied with the consultation.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Add more topics as needed, following the same format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary [Summarize the main symptoms the patient has] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summarize the main symptoms the patient wants addressed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "Reason for Visit:" - [describe the primary reason(s) for the patient's visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) "History of Presenting Illness:" [document the chronology, characteristics, severity, and any associated symptoms related to the patient's current illness or complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.) "Past Medical History:" - [list the patient's significant past medical conditions and diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) "Medications:" - [list all current medications, including dosage, frequency, and route, and any over-the-counter supplements or herbal remedies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) "Allergies:" - [list all known allergies to medications, food, or environmental factors, and describe the nature of any reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) "Social History:" - "Smoking Status: " [document the patient's smoking status, including type and quantity if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single sentence.) - "Alcohol Consumption: " [document the patient's alcohol consumption habits, including frequency and quantity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single sentence.) - "Occupation: " [document the patient's current occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single sentence.) - "Living Situation: " [document the patient's living arrangements and social support system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single sentence.) "Family History:" [document any relevant medical conditions present in the patient's family history that may impact their health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.) "Review of Systems:" - "General: " [document any general symptoms such as fever, weight loss, fatigue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Cardiovascular: " [document any cardiovascular symptoms such as chest pain, palpitations, shortness of breath] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Respiratory: " [document any respiratory symptoms such as cough, wheezing, dyspnea] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Gastrointestinal: " [document any gastrointestinal symptoms such as nausea, vomiting, abdominal pain, changes in bowel habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Musculoskeletal: " [document any musculoskeletal symptoms such as joint pain, muscle weakness, back pain] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Neurological: " [document any neurological symptoms such as headaches, dizziness, numbness, tingling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Endocrine: " [document any endocrine symptoms such as changes in thirst, urination, heat/cold intolerance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) - "Psychological: " [document any psychological symptoms such as anxiety, depression, mood changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list of positive and negative findings.) "Physical Examination:" - "General Appearance: " [document the patient's overall general appearance, including signs of distress, nutritional status, and hygiene] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) - "Vital Signs: " [document the patient's vital signs including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise list of values with units.) - "Cardiovascular Exam: " [document findings from the cardiovascular examination, including heart sounds, murmurs, and peripheral pulses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) - "Respiratory Exam: " [document findings from the respiratory examination, including breath sounds, respiratory effort, and chest wall movement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) - "Abdominal Exam: " [document findings from the abdominal examination, including palpation, auscultation, and percussion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) - "Musculoskeletal Exam: " [document findings from the musculoskeletal examination, including range of motion, strength, and presence of tenderness or swelling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) - "Neurological Exam: " [document findings from the neurological examination, including mental status, cranial nerves, motor, sensory, and reflexes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a concise description.) "Investigations:" - [list any ordered or reviewed diagnostic tests, imaging, or laboratory results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list including type of investigation and key findings.) "Assessment:" [provide a concise summary of the patient's main problems, the clinician’s differential diagnoses, and the clinician’s working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences. Do not invent or infer a diagnosis.) "Plan:" - "Pharmacological Management: " [list any prescribed medications, including dosage, frequency, and duration, and rationale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) - "Non-Pharmacological Management: " [describe any non-pharmacological interventions, such as lifestyle modifications, physical therapy, or counseling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) - "Referrals: " [list any referrals to specialists or other healthcare professionals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) - "Follow-up: " [describe the follow-up plan, including when and how the patient should be seen again] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) - "Patient Education/Counselling: " [document any education or counselling provided to the patient regarding their condition, treatment, or self-care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a brief bulleted list.) Next Steps: [Summarize the specific next actions for the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thank you for trusting me with your care. If you have any questions or concerns about anything we discussed, please do not hesitate to reach out. Warm regards, [Clinician Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Qualifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Role/Title] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)