Templates
refined clinic letter
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Caramel Latte
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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]
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