Plan:
[If mentioned, a numbered list consisting of the plan from the letter]
[The main body of the letter, addressed to the patient]
Summary of Results:
[A list of investigation results]
Medical ST4 Miller Clerking
Presenting Complaint:
[The reason for the patient attending, the presenting complaint, aiming for 1 to 3 words and up to one sentence only. For example: haematemesis, melaena]
History of Presenting Complaint:
[In note format, include key symptoms or events related to the patient's presenting complaint using short sentences. Do not include the patient's name. Also include relevant information from any relatives and any other professionals]
Past Medical History:
[A bulleted list of the medical problems the patient has had in the past, if diabetes is mentioned, include the latest HbA1c (if mentioned). If asthma or COPD is mentioned, include any lung function studies (if mentioned)]
Medication History:
[A list of the patient's current medications e.g. Atorvastatin 20mg PO ON]
Allergic History:
[If mentioned, include any allergies here]
Social History:
[Include here information about the wider social situation of the patient. Who they live with, if they have a package of care, how they move around and if they drink alcohol or smoke cigarettes, if mentioned]
On Examination:
[Any relevant examination findings mentioned]
Investigations:
[A list of investigations mentioned, if you have already included these in the past medical history field, do not repeat them here]
Impression:
[The impression, the diagnosis or diagnoses]
Plan:
[A numbeed list of actions, the plan for the patient's admission, include an empty box ("[_]") after each item])]
For each patient discussed, include the following:
- [Patient name and MRN].
- [A short summary of what was discussed about this patient including current issues or diagnoses].
- [The plan discussed and any outcomes for this patient from the meeting]
Investigations:
[A list of investigations performed and results, if mentioned]
[The main body of the referral response, writing to another medical professional]
Impression:
[The diagnosis or impression]
Suggest:
[A numbered list of suggestions to the managing team]
Diagnosis:
[The diagnosis for which they are being seen in clinic, for example "Crohn's Disease"]
Other Medical Diagnoses
[A list of other diagnoses the patient has from their past medical history]
Medications:
[A list of current medication the patient takes. If there are changes to medications mentioned, change them in this list and make the item that has changed bold]
Investigations:
[A list of investigations and their results, if mentioned]
Plan:
[A numbered list consisting of the plan following this appointment for investigations and management changes]
[A letter documenting the clinical consultation, written to the patient's GP. Include what was discussed, the plan for follow up and any planned investigations]
Presenting Complaint:
[The reason for the patient attending, the presenting complaint, aiming for 1 to 3 words and up to one sentence only. For example: haematemesis, melaena]
Past Medical History
[A bulleted list of the medical problems the patient has had in the past, if diabetes is mentioned, include the latest HbA1c (if mentioned). If asthma or COPD is mentioned, include any lung function studies (if mentioned)]
Diagnosis:
[The diagnosis mentioned in the dictation or transcription. If not mentioned, insert your diagnosis based upon the information provided]
I had the pleasure of meeting [patient name] in Same Day Emergency Care today.
[A letter to the GP documenting the clinical consultation. Include the patient's symptoms, pertinent past medical history, examination findings and pertinent investigation results (if mentioned)]
Investigations:
[A list of investigations and their results]
Plan:
[A numbered list consisting of the plan following the patient's attendance.]
Indication:
[The clinical reason for the endoscopy (e.g., "heartburn, dysphagia, iron-deficiency anaemia"). Include any previous investigations or endoscopies that led to this procedure if mentioned.]
Findings:
[Endoscopic findings grouped by anatomical areas. Use format: "In the [anatomical area], [finding description]." For Barrett's Oesophagus, include C/M staging (e.g., "C5M7 Barrett's Oesophagus") and any measurements (e.g., "Top of Gastric Folds 40cm"). When biopsies are taken, include specimen pot identifier in brackets after biopsy site (e.g., "Antral biopsies taken (Pot A)"). Recognise endoscopic anatomy: Upper GI - Oesophagus, GOJ, Cardia, Body, Antrum, Pylorus, D1, D2 (often mis-transcribed as "DT"), D3. Lower GI - Terminal ileum, Caecum, Ascending colon, Hepatic flexure, Transverse colon, Splenic flexure, Descending colon, Sigmoid, Rectum.]
Therapy:
[Any therapeutic interventions performed (e.g., polypectomy, PEG placement, endoscopic clips, dilatation). Omit this entire section if no therapy mentioned.]
Plan:
[Post-procedure management including follow-up procedures, further investigations, histology review, or clinical follow-up appointments.]
Histology:
[List each specimen pot sent to the laboratory with its contents and anatomical source. Format: "Pot [identifier]: [Anatomical location and type of tissue] (e.g., "Pot A: Antral biopsies for H. pylori", "Pot 1: Sigmoid polyp", "Pot 2: Duodenal biopsies for coeliac screen"). Include any special staining requests if mentioned.]
Breakdown of Findings:
[Systematic review of findings by anatomical region examined. For Upper GI procedures list: Oesophagus, Gastro-Oesophageal Junction (GOJ), Stomach, Antrum, Pylorus, Duodenum First Part (D1), Duodenum Second Part (D2). For Lower GI procedures list: Terminal ileum, Caecum, Ascending colon, Hepatic flexure, Transverse colon, Splenic flexure, Descending colon, Sigmoid, Rectum. State "Normal" or "No abnormality detected" if area was examined and normal. If an anatomical area is not mentioned in the procedure, assume it was examined and was normal.]
# MDT/Supervisor Discussion Template
## Meeting Details:
**Date:** [Meeting date]
**Meeting Type:** [MDT/Supervisor discussion/Case review/etc.]
**Attendees:** [Who was present]
**Discussed by:** [Name of person presenting cases]
## Patient(s) Discussed:
[If single patient: Patient name, DOB, MRN]
[If multiple patients: List patients with brief identifiers]
## Discussion Summary:
[A summary of the discussion from this meeting, including the plan or outcome agreed upon]
## Action Points:
1. [_] [Specific action item with responsible person]
2. [_] [Investigation/procedure to be arranged]
3. [_] [Follow-up requirements]
4. [_] [Any urgent actions needed]
## Next Review:
[When patient(s) will be discussed again, if applicable]
Medical ST5 Miller Clerking
[Current Date] [Current Time]
Presenting Complaint:
[The reason for attendance in 1-3 words]
History of Presenting Complaint:
[Chronological narrative of current illness using short, clear sentences. Include:
- Onset, character, location, radiation, timing, exacerbating/relieving factors
- Associated symptoms
- Impact on daily activities
- Previous similar episodes
- Relevant collateral history from relatives/carers
- Any relevant background from other healthcare professionals
Do not repeat patient's name throughout. Be concise and tell a chronological story to the reader. Do not include subjective descriptions of the symptoms e.g. "severe" or use unnecessarily long words.]
Past Medical History:
[Bulleted list of significant medical conditions with relevant details:]
• [Condition with year if mentioned]
• Diabetes mellitus - latest HbA1c: [value] mmol/mol ([date])
• Asthma/COPD - latest spirometry: FEV1 [value], FVC [value] ([date])
• [Previous surgeries with dates]
• [Other significant medical history]
Drug History:
• [Drug name] [dose][units] [route] [frequency]
• [Example: Omeprazole 20mg PO OD]
• [Example: Clopidogrel 75mg PO OD]
Recently Stopped Medications: [If relevant]
• [Medication] - stopped [date/reason]
Allergy History:
[If allergies mentioned:]
• [Allergen] - [Reaction type] ([severity if mentioned])
• NKDA [if no known drug allergies stated]
Social History:
[Living situation. Who they live with, housing type, if mentioned]
[Mobility. Walking aids, stairs, transfers, if mentioned]
[Carers. Formal/informal care arrangements, if mentioned]
[Occupation. Current/previous if relevant, if mentioned]
[Smoking. Never/Ex-smoker/Current - pack years if mentioned]
[Alcohol. Units per week/Never/Ex-drinker - if mentioned]
[Functional Status: Impact on activities of daily living, if mentioned]
On Examination:
[General Appearance. Alert, well/unwell, distressed, if mentioned]
Observations:: [If mentioned - HR, BP, Temp, RR, O2 sats (do not use subscripts)]
• Abdomen: [Inspection, palpation, percussion, auscultation findings. If not commented upon, document as normal]
• Cardiovascular: [Heart sounds, murmurs, peripheral pulses, oedema. If not commented upon, document as normal]
• Respiratory: [Chest expansion, percussion, auscultation. If not commented upon, document as normal]
• Neurological: [If examined.]
• Other: [Any other relevant examination findings, if mentioned]
Investigations:
• [Test name] ([date, if mentioned, do not include include today's date on results, list without a date]): [Result without units]
• [Example: Hb 85]
• [Imaging type] ([date, if mentioned]): [Key findings]
• [Example: CT Abdomen/Pelvis (15/03/24): Sigmoid diverticulosis, no perforation]
Impression:
[Main diagnosis]
Differential Diagnoses: [Only if multiple possibilities discussed]
[Secondary issues. Relevant comorbidities affecting management. If mentioned]
Management Plan:
1. [A numbered list documenting the management plan to be undertaken, if mentioned, include:
- Immediate management/monitoring,
- Investigation requests,
- Treatment interventions - medications, procedures,
- Discharge planning/follow-up arrangements,
- Patient education/lifestyle advice,
- Referrals to other specialties if needed,
- Which ward or specialty the patient would be best admitted to e.g. "Respiratory Bed",
- Escalation plan that was discussed - whether the patient is suitable for CPR, ITU and/or NIV.]
# Handover Meeting Template
## Patients Discussed:
### Patient 1:
**Name:** [Patient name]
**MRN:** [Medical record number]
**Summary:** [A short summary of what was discussed about this patient including current issues or diagnoses]
**Plan:** [The plan discussed and any outcomes for this patient from the meeting]
### Patient 2:
**Name:** [Patient name]
**MRN:** [Medical record number]
**Summary:** [A short summary of what was discussed about this patient including current issues or diagnoses]
**Plan:** [The plan discussed and any outcomes for this patient from the meeting]
### Patient 3:
**Name:** [Patient name]
**MRN:** [Medical record number]
**Summary:** [A short summary of what was discussed about this patient including current issues or diagnoses]
**Plan:** [The plan discussed and any outcomes for this patient from the meeting]
[Continue for additional patients as needed]
## Outstanding Tasks:
• [Task requiring follow-up]
• [Investigation results to chase]
• [Referrals pending]
## Patients at Risk/Watch:
• [Patient name] - [Risk factor/concern]
• [Patient name] - [Risk factor/concern]
## General Issues Discussed:
[Any ward-level issues, staffing concerns, or general points raised during handover]
Investigations:
[A list of investigations performed and results, if mentioned]
[Investigation] ([date]): [Result/findings]
[Investigation] ([date]): [Result/findings]
[Investigation] ([date]): [Result/findings]
Referral Response:
[The main body of the referral response, writing to another medical professional]
Impression:
[The diagnosis or impression]
Suggest:
[Numbered list of suggestions to the managing team]
[Management recommendations]
[Investigation requests]
[Follow-up arrangements]
[When to re-refer if needed]
Reason for Call:
[Brief description of why emergency call was made and initial concerns]
A-E Assessment:
A - Airway: [Include only if airway issues mentioned or interventions performed]
B - Breathing: [Include respiratory findings, oxygen saturations, interventions - only mention what was assessed or abnormal]
C - Circulation: [Include heart rate, blood pressure, circulation findings - only document what was mentioned or concerning]
D - Disability: [Include neurological assessment, GCS, pupils, blood glucose - only if assessed or abnormal]
E - Exposure: [Include temperature, skin findings, other examination findings - only if mentioned]
Investigations:
[Document which investigations were reviewed, including results if mentioned]
Impression:
[Clinical impression and working diagnosis]
Plan:
[Management plan including immediate interventions, ongoing treatment, and follow-up arrangements]
Team Leader: [Name and grade]
Documentation Date: [When notes completed]
Issues:
1. [Issue 1 with any associated information in bullet points underneath]
- [Additional information about issue 1]
- [Further additional information about issue 1]
2. [Issue 2 with any associated information in bullet points underneath]
- [Additional information about issue 2]
- [Further additional information about issue 2]
...
[Further information including background, examination findings and history]
Impression:
[Diagnosis or diagnoses]
Plan
1. [First item in the plan]
2. [Second plan item]
...
Plan:
1. [If mentioned, numbered list of next steps, follow-up appointments, or actions required]
2. [Additional plan items]
3. [Further management steps]
[The main body of the letter, addressed to the patient, explaining the results in patient-friendly language and any relevant clinical context]
If you have any questions or concerns about these results, please do not hesitate to contact us.
Summary of Results:
[List of investigation results with dates using medical terminology for GP reference]
ST5 Miller Clinical Review Note
Reason for review:
[Brief reason for consultation in 3–8 words]
Background:
[Relevant background only if discussed or clearly implied.
2–4 short sentences maximum.
Do not restate full PMH unless directly relevant.]
History:
[Salient history since last review or current concern.
Focus on what has changed, what matters now, and what the patient reported.
Short, factual sentences.
Do not force a full HPC structure.
Do not invent negatives.]
Examination:
[Only include findings explicitly mentioned.
If not discussed, write:
"Examination findings not discussed during this consultation."]
Investigations:
[List only investigations reviewed or discussed.
Use simple bullets if needed:
Test (date): key result
Imaging (date): headline finding
If none discussed, omit this section.]
Impression:
[Working diagnosis or clinical assessment.
Include uncertainty if expressed.
Include differentials only if discussed.]
Plan:
1. [Immediate actions or monitoring, if mentioned]
2. [Investigations to arrange or await, if mentioned]
3. [Medication changes, if mentioned]
4. [Procedures or interventions, if mentioned]
5. [Follow-up arrangements, if mentioned]
6. [Safety-netting advice, if discussed]
7. [Escalation or ceilings of care, only if discussed]
[Patient name], [Age], [Medical Records Number].
[New or Follow up]
Main issue was [reason for referral / known gastro diagnosis].
[Bullet-point notes capturing the story and your thinking.]
Plan was
[very brief plan in bullet points].
[Queries: if any mentioned for discussion in supervision, in bullet points].
Medical ST5 Miller Review
Reason:
[Why reviewed]
History:
[Key points only]
Examination:
[If discussed]
Impression:
[Assessment]
Plan:
[Numbered list of items in the plan if mentioned]
Diagnosis:
[Primary gastroenterology condition being managed] - [When diagnosed if mentioned]
Other Medical Diagnoses:
[Bulleted list of comorbidities and past medical history:]
• [Diagnosis] - [Status/control if relevant]
• [Example: Type 2 Diabetes Mellitus - HbA1c 48 mmol/mol (good control)]
• [Example: Hypertension]
• [Previous surgeries with dates]
Current Medications:
[List all current medications, if dose, units, route or frequency is not transcribed, do not include it and just state the drug name]
• [Drug name] [dose][units] [route] [frequency]
• [New medication] [dose][units] [route] [frequency] - Started today
• [Stopped medication] [dose][units] [route] [frequency] - Discontinued today
• [Modified medication] [NEW dose][units] [route] [frequency] - Dose changed from [old dose]
Investigations:
• [Test name] ([date]): [Result] [Reference range (only if transcribed)] - [Clinical significance (only if transcribed)]
• [Imaging type] ([date]): [Key findings and clinical relevance]
• [Procedure] ([date]): [Findings, interventions, histology if available]
• [Additional tests with clinical interpretation]
Management Plan:
1. [The first item in the plan]
2. [Second item in the plan]
...
3. Follow up in [Timeframe]
I had the pleasure of [meeting/speaking on the phone] to [Mr/Mrs/Ms Surname] in gastroenterology clinic.
[Free-form letter content including current status, examination findings, investigation results, management changes, follow-up plans, and any actions required from GP. Write in natural paragraph format as a clinical letter. FOCUS ON CREATING A LETTER BASED UPON THE DIAGNOSIS, INVESTIGATIONS, PMH, MEDICATION LIST AND PLAN SECTIONS PLUS THE DICTATION AT THE END OF THE TRANSCRIPTION - IGNORE THE CONSULTATION UNLESS PERTINENT INFORMATION HAS BEEN MISSED FROM THE DICTATION]