Neurology Correspondence to Referring Physician

The 'Sameer Letter back to referring clinician' template by s10.ai is crafted for neurologists to effectively relay diagnostic findings and management plans to the referring clinician. This comprehensive template encompasses sections for medical issues, history of presenting complaints, past medical history, social history, current medications, examination findings, investigations, impression, and plan. It is particularly advantageous for documenting intricate neurological cases, such as chronic migraines, ensuring thorough communication among healthcare providers. Implementing this template within s10.ai, the AI medical scribe, optimizes documentation processes and enhances clinical workflow efficiency.

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Template Structure

Organized sections for comprehensive clinical documentation

Medical Concerns:

[state the primary neurology medical concern] (most significant presenting symptoms in bullet points, maximum 5)

I appreciate your referral of the aforementioned patient to me.

History of Presenting Symptoms: [Provide details of presenting symptoms related to the primary concern] (detailed description of HPI, including symptoms, duration, severity, and any other pertinent details.)

Relevant Past Medical History: [Provide patient past medical history] (Summarize past medical history in bullet points. Include dates and status of the issue if mentioned.)

[Describe patient's social history] (brief social history of smoking, alcohol, family history, and employment if mentioned)

Current Medications: [list current medications] (Include dose, route, frequency. Use bullet points) (omit if no medications mentioned)

Examination:

[physical examination] (Bullet points, organized in a cohesive manner. Add normal exam findings relevant to the impression or diagnosis if not mentioned. Include typical head-to-toe examination if mentioned, also include vital signs if mentioned - BP, HR, RR, SpO2. Include neurological examination.)

(organize points in order of higher functions, cranial nerves, cerebellar signs, motor examination, tendon reflexes, sensory examination, and gait)

Investigations

[summarize clinical investigations] (bullet points of only radiological, blood tests, and technical studies if available)

Impression:

[Summarize impression based on clinical information] (bullet points, impression list with explanation.)

[Summarize differential diagnosis] (Only include if mentioned.)

Plan:

- [Detail the first key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note)

- [Detail the second key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note)

- [Detail the third key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note)

(use as many bullet points as necessary to comprehensively capture the plan)

(medication names in capital)

(warnings and important points if any, should be underlined)

Patient Education: [describe patient education provided by the clinician during the consultation] (Use bullet points)

Should you have any further questions regarding the above patient, please do not hesitate to contact me.

Sample Clinical Note

Example of completed documentation using this template

Medical Issues:
- Chronic migraine headaches
"Thank you for referring the above patient to me."
History of presenting complaints: The patient has been suffering from chronic migraine headaches for the last 5 years. The headaches occur about 3-4 times weekly, with each episode lasting between 4 to 6 hours. The pain is described as throbbing and is frequently accompanied by nausea and sensitivity to light and sound.
Relevant Past medical History:
- Hypertension, diagnosed in 2018, currently well-controlled
- Asthma, diagnosed in childhood, managed with inhalers
The patient is a non-smoker, consumes alcohol occasionally, and works as a software engineer. There is a family history of migraines, as the patient's mother also experiences them.
Current medications:
- AMLODIPINE 5mg, oral, once daily
- SALBUTAMOL inhaler, 100mcg, as needed
Examination:
- Higher functions: Alert and oriented
- Cranial nerves: Intact
- Cerebellar signs: No dysmetria or ataxia
- Motor examination: Normal muscle tone and strength
- Tendon reflexes: Normal
- Sensory examination: No deficits
- Gait: Normal
- Vital signs: BP 130/80 mmHg, HR 72 bpm, RR 16 breaths/min, SpO2 98%
Investigations:
- MRI brain: No significant abnormalities
- Blood tests: Normal CBC and metabolic panel
Impression:
- Chronic migraine headaches
Plan:
- Initiate prophylactic treatment with TOPIRAMATE 25mg, oral, once daily
- Continue current antihypertensive and asthma management
- Schedule follow-up in 3 months to assess response to treatment
Patient education:
- Advised on lifestyle modifications to reduce migraine triggers, such as maintaining a regular sleep schedule and managing stress
- Discussed the importance of medication adherence
"Should you have any further questions regarding the above patient, please do not hesitate to contact me."

Clinical Benefits

Key advantages of using this template in clinical practice

This comprehensive neurology clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of patient information. It covers all essential aspects, including the primary neurology medical issue, detailed history of presenting complaints, relevant past medical history, and social history. The template also includes sections for current medications, thorough physical examination findings, and a summary of clinical investigations. Clinicians can easily document their impression and differential diagnosis, followed by a structured plan and patient education. This template is an invaluable tool for enhancing clinical workflows, improving patient care, and ensuring compliance with medical documentation standards. Explore and implement this template to optimize your practice and provide high-quality care.

Frequently Asked Questions

Common questions about this template and its usage

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