OMFS Initial Consultation Letter - Lesion Assessment & Surgical Planning

**Diagnosis:** [List all lesions alphabetically starting with Lesion A, including the clinician's clinical diagnosis or impression, specific site, and size in millimetres] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as a numbered list.) **Accompanied by:** [Name and relationship to patient such as wife, husband, partner, son, daughter, carer, or friend] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Referred by:** [Name including title and role of referrer, or state self-referral] (If self-referral, insert "Self". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Forms completed:** [Forms completed or provided by patient regarding medical history and skin lesions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Reason for attendance:** [Reason for consultation including specific concerns such as possible basal cell carcinoma, squamous cell carcinoma, melanoma, lentigo maligna, changing mole, benign mole, seborrhoeic keratosis, actinic keratosis, skin cyst, skin lesion, patch, lump, or previous surgery concerns] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Lesion A:** [Detailed history including site, size, duration, growth, bleeding, pain, colour change becoming lighter or darker, presence of crust, presence of lump, details of any recurrence, severity, aggravating or alleviating factors, associated symptoms, nature, any previous treatments and responses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Examination findings including size and site, dermatoscopic or magnified findings, clinical diagnosis or description, presence of fixation, presence of other features] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Additional lesions:** [Follow the same structure as Lesion A for each additional lesion, using alphabetical sequence such as Lesion B, Lesion C] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points for each lesion.) **Lymph node examination:** [Presence of any lumps, features of any lymph node or lymph gland examination abnormalities, normal lymph node examination with site of area examined] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Skin areas examined:** [State which skin areas examined such as head and neck, torso, full skin check, offer to examine other areas and if offer declined] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Investigation results:** [Investigation results including imaging and laboratory tests pertinent to surgical assessment with dates] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Risk factors for skin lesions:** [Immunocompromised state and reasons, previous skin cancer history with details of what occurred when and outcome, sun exposure details and timing, history of sunburn, outdoor hobbies or occupation, time living abroad with details of where and when, family history of skin cancer] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points including both negative and positive answers.) **Risk factors for oral lesions:** [Smoking, alcohol, previous mouth skin problems, previous skin problems, eye mucosal problems, steroid therapy] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Mention confirmed positives or negatives only.) **Skin type:** [Skin type using Roman numerals I to IV] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **General health:** PS [Performance status as a number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Frailty Score [Frailty score as a number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Medical history:** [Past medical and surgical history highlighting previous surgeries, hospitalisations, outcomes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Drug history:** [Current medications including anticoagulants, pain management, or antibiotics] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. State "NO BLOOD THINNERS" if not on antiplatelet or anticoagulant medication.) **Allergy history:** [Allergies including medications, latex, or materials used in surgical procedures] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else state "NO allergies".) **Scar formation:** [Personal or family history of good healing of skin or any abnormal scar formation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Social history:** [Occupation and hobbies involving activity which may impact on post-operative healing] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Assessment and plan:** **Lesion A:** [The clinician's differential diagnosis after considering other potential surgical or medical conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) [Surgical treatment planned including type of anaesthesia, operation planned, site, size in millimetres, reconstruction plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. State type of anaesthesia such as LA or LA and IVS or GA first, then operation planned such as punch biopsy, shave biopsy, excision diagnostic biopsy, primary wide local excision with curative intent, secondary wide local excision with curative intent, then lesion identifier, then site, then size in millimetres, then reconstruction plan as direct closure, local flap, or full thickness skin graft with donor site.) **Additional lesions:** [Follow the same structure as Lesion A for each additional lesion] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Operation details:** [Date of surgery, arrival time, operation slot needed in minutes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Procedure codes:** [Procedure codes as stated] (Only include if patient using medical insurance. Do not include if patient is self-funding. Include both excision or biopsy code and code for reconstruction by local flap or graft if that is part of surgical plan. Use the following codes: 1st excision of malignant lesion head and neck S0602, 1st excision of malignant lesion trunk and limbs S0603, 2nd excision of malignant lesion head and neck S0604, 2nd excision of malignant lesion trunk and limbs S0605, excision of lesion of skin x3 head and neck S0632, excision of lesion of skin x3 trunk and limbs S0633, excision of lesion of skin 4 plus head and neck S0642, excision of lesion of skin 4 plus trunk and limbs S0643, removal of lipoma S0656, benign lesion head and neck not scalp S0654, benign lesion head and neck not scalp with flap S0655, benign lesion trunk and limbs greater than 10 centimetres or scalp greater than 5 centimetres S0652, benign lesion trunk and limbs less than 10 centimetres or scalp less than 5 centimetres S0651, biopsy of skin S1500, shave biopsy of skin S1420, excision of pinna D0210, excision of lesion of lip F0200, excision lesion mouth F3810, biopsy of mouth lesion F4210, excision of lesion of palate F2810, excision of lesion tongue F2310, biopsy of salivary gland F4810, local flap less than 9 centimetres S2500, local flap more than 9 centimetres S2502, full thickness skin graft head and neck up to 9 centimetres S3624, full thickness skin graft trunk and limbs up to 9 centimetres S3622, full thickness skin graft head and neck additional 16 centimetres S3625, reconstruction of lip using skin flap F0420, coronectomy F0911, surgical removal of tooth or teeth F0950, surgical removal wisdom teeth F0910. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Second operation:** [Date if planned, state date to be confirmed if no date set] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Removal of sutures:** [State if required or not, if required mention when and by whom] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Review plans:** [State if in person at hospital or by video or phone, and when review needed in days, weeks, or months] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Pre-operative preparation:** [Investigations planned such as previous pathology reports or blood tests needed for definitive diagnosis or pre-operative planning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Informed consent commenced including discussion of procedure, potential risks, benefits, alternatives including radiotherapy and no treatment, and information given about digital consent] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Given to the patient:** [Advice or information given] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Leaflets by description of content] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Prescriptions, anything else given to patient, or to be sent to patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Post-operative care:** [Post-operative care plan covering expected hospital stay, pain management, wound care, follow-up appointments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Optimising healing post-operatively by avoiding named hobbies and for how long] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Concerns and expectations:** [Specific patient or family concerns or expectations addressed during consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else state "No further concerns or expectations".) **Other outcomes:** [Relevant referrals for multidisciplinary care or further evaluation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Plan:** [Detailed plan including surgical treatment for each lesion with type of anaesthesia, operation planned, site, size in millimetres, reconstruction plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. State type of anaesthesia such as LA or LA and IVS or GA first, then operation planned such as punch biopsy, shave biopsy, excision diagnostic biopsy, primary wide local excision with curative intent, secondary wide local excision with curative intent, then lesion identifier, then site, then size in millimetres, then reconstruction plan as local flap, full thickness skin graft with donor site, or add "and direct closure" if no reconstruction mentioned. Only include procedure codes in this section if patient is using medical insurance, do not mention codes if patient is self-funding.) [Date of surgery and place in hospital where operation will take place at Mount Alvernia Hospital, arrival time, surgery to take place around 15 minutes later if in minor operations or around 30 minutes later if in day surgery unit] (Only include if surgery is planned. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Specific instructions such as tests needed before surgery and when, specific instructions about stopping or continuing medication] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "Thank you for coming to see me today" [mention "in the company of" with name and relationship to patient if applicable] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "at the kind suggestion of" [name of referrer] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.). "Thank you" [first name of referrer if present in transcript] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.). [Summary for patient using first person pronoun "you", less detailed using simple language, always define and explain medical terms not described by patient in plain English] (Only include if surgery is planned. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "We looked together at a drawing of what the possible surgery would involve, and a copy is enclosed here. We have taken clinical photography for thorough documentation purposes. We have a plan as above and I have given you some local anaesthetic cream" [only for skin lesions if mentioned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) "and written information on your procedure. Mount Alvernia Hospital uses a consent form system called Concentric and you will also receive a link to a digital consent form with helpful information, which we would be grateful if you could complete if you are happy to proceed. **<u>Please can you sign it before the day of surgery.</u>** I look forward to seeing you then and please do let me know if you have any further questions." (Only include the above three paragraphs if surgery is planned. If not, state: "Please do let me know if you have any further questions.") BW CN cc GP cc Dr Pink (Only include Dr Pink if mentioned in transcript, contextual notes, or clinical note.) <u>DRAWING FOR PATIENT</u> **Enclosures to letter:** [Any enclosures mentioned] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Tasks for office:** [Date of surgery, arrival time, operative slot time, venue for surgery] (Default venue will be Day Surgery Unit at Mount Alvernia Hospital, cases will be done in minor operations if minor operations is mentioned, or in main theatre if having general anaesthetic or intravenous sedation. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Procedure codes] (Only include if patient using medical insurance. Do not include if patient is self-funding. Include both excision or biopsy code and code for reconstruction by local flap or graft if that is part of surgical plan. Use the following codes: 1st excision of malignant lesion head and neck S0602, 1st excision of malignant lesion trunk and limbs S0603, 2nd excision of malignant lesion head and neck S0604, 2nd excision of malignant lesion trunk and limbs S0605, excision of lesion of skin x3 head and neck S0632, excision of lesion of skin x3 trunk and limbs S0633, excision of lesion of skin 4 plus head and neck S0642, excision of lesion of skin 4 plus trunk and limbs S0643, removal of lipoma S0656, benign lesion head and neck not scalp S0654, benign lesion head and neck not scalp with flap S0655, benign lesion trunk and limbs greater than 10 centimetres or scalp greater than 5 centimetres S0652, benign lesion trunk and limbs less than 10 centimetres or scalp less than 5 centimetres S0651, biopsy of skin S1500, shave biopsy of skin S1420, excision of pinna D0210, excision of lesion of lip F0200, excision lesion mouth F3810, biopsy of mouth lesion F4210, excision of lesion of palate F2810, excision of lesion tongue F2310, biopsy of salivary gland F4810, local flap less than 9 centimetres S2500, local flap more than 9 centimetres S2502, full thickness skin graft head and neck up to 9 centimetres S3624, full thickness skin graft trunk and limbs up to 9 centimetres S3622, full thickness skin graft head and neck additional 16 centimetres S3625, reconstruction of lip using skin flap F0420, coronectomy F0911, surgical removal of tooth or teeth F0950, surgical removal wisdom teeth F0910. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) FPP CN Fee £ [fee in pounds as stated] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Type of review] (State if video, phone call, or face to face, state what results of investigations are required at review, if surgery taking place this review will be with pathology results unless only surgery planned is removal of teeth or surgery is arthrocentesis, if radiological investigation or blood test or microbiology test is planned state if has been done or where it will be done and if office needs to deal with any forms or be in touch with patient. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pathology form needed] (State no if not for surgery, if tissue being removed at operation apart from tooth or teeth then state yes and specify for BALA if skin lesion to be operated on or for Di Palma if mouth or salivary gland. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Data sheet needed] (State no if all diagnoses are benign. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Patient discharge status and notes management] (If patient is discharged state so and say what should happen to notes, if patient has had cancer of any kind notes should be kept, otherwise state notes to be scanned and shredded. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)