Surgical Outpatient Consultation Letter

[Date of consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write the date in DD/MM/YYYY format.) [Referring clinician name and practice details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) [Patient full name and date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Dear [Referring clinician salutation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single greeting line beginning with Dear followed by the clinician's title and surname.), Diagnosis / Ongoing Issues: [Clinician's explicitly stated primary diagnosis and any ongoing surgical or medical issues being managed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a concise list with each item on a new line.) Past Medical History: [Past medical conditions, previous surgeries and relevant hospital admissions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) Allergy: [Documented allergies including the allergen and nature of the reaction] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) BMI: [Patient's recorded BMI value and weight category] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Smoking / Alcohol: [Smoking status and alcohol use including frequency and quantity where stated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) Performance Status: [Patient's functional and performance status as stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single line.) Management Plan: [Overall management plan as outlined by the clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in one concise line.) [History of the presenting complaint including onset, duration, character, associated symptoms, relevant investigations to date and impact on the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single flowing paragraph of full sentences.) [Findings from physical examination and point of care ultrasound including relevant positive and negative findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single flowing paragraph of full sentences.) [Clinician's explicitly stated possible diagnosis, further investigations recommended and proposed treatment options being considered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a single flowing paragraph of full sentences.) [Follow-up arrangements including timing, location and responsible clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single flowing paragraph of full sentences.) [Surgical risks discussed with the patient relevant to the procedure recommended] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If laparoscopic cholecystectomy is the recommended procedure, list the risks of laparoscopic cholecystectomy as per current guidelines including general anaesthetic risks, bleeding, infection, bile duct injury, bile leak, conversion to open surgery, port site hernia, retained stones and mortality. If umbilical hernia repair is the recommended procedure, list the risks as per current guidelines including general or local anaesthetic risks, bleeding, infection, recurrence, seroma, mesh complications where relevant and injury to surrounding structures. If inguinal hernia repair is the recommended procedure, list the risks as per current guidelines including general or local anaesthetic risks, bleeding, infection, recurrence, chronic groin pain, seroma, injury to the vas deferens or testicular vessels, mesh complications where relevant and conversion between laparoscopic and open approach where applicable. If any other surgical procedure is recommended, list the relevant risks as per current guidelines for that procedure. Write as a list with each risk on a new line.) [Closing statement confirming the patient has been informed of their ability to follow up with the surgeon] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single sentence confirming the patient was advised they may contact the surgeon via email or book a telephone consultation to discuss surgical risks and alternative treatment options.) [Surgeon name, qualifications and contact details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write each detail on a new line.)