Patient Name: John Doe
Date of Birth: 15 March 1980
Date of Visit: 1 November 2024
Dear Dr. Emily Smith,
I am writing to provide a summary of the medical condition and treatment plan for John Doe.
Diagnosis:
John has been diagnosed with a torn anterior cruciate ligament (ACL) in his right knee.
Medical History:
John has a history of hypertension and underwent a previous meniscus repair surgery in 2018.
Current Medications:
- Lisinopril 10 mg daily
- Ibuprofen 400 mg as needed for pain
Treatment Plan:
John is scheduled for ACL reconstruction surgery on 15 November 2024. Post-surgery, he will undergo a structured rehabilitation program focusing on range of motion and strengthening exercises.
Patient Accommodations:
John will require crutches for mobility and a knee brace for support during the initial recovery phase.
Please feel free to contact me if you require any further information.
Sincerely,
Dr. Thomas Kelly
Orthopaedic Surgery Department
thomas.kelly@hospitalemail.com
555-123-4567
Patient Name: [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date of Birth: [patient date of birth] (only include patient date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date of Visit: [date of visit] (only include date of visit if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dear [recipient name] (only include recipient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.),
I am writing to provide a summary of the medical condition and treatment plan for [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
Diagnosis:
[diagnosis] (only include diagnosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History:
[past medical history] (only include past medical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Current Medications:
[current medications] (only include current medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Treatment Plan:
[treatment plan] (only include treatment plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Patient Accommodations:
[patient accommodations] (only include patient accommodations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Please feel free to contact me if you require any further information.
Sincerely,
[Doctor's Name] (only include Doctor's Name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[Doctor's Contact Information] (only include Doctor's Contact Information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 include 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.) relevant information from the transcript.)
