Surgical Oncology Consult

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert reason for consultation, diagnosis, lesion, mass, cancer, operative issue, postoperative issue, or surgical oncology/general surgery problem]

Template

Dear Dr. [Referring physician last name]: Thank you for facilitating this referral. As you know, [Patient name] was seen in clinic today for consultation regarding [referral question, diagnosis, lesion, mass, cancer, operative issue, postoperative issue, or surgical oncology/general surgery problem]. [Add one or two concise sentences of essential context if needed, such as biopsy-proven diagnosis, concerning imaging finding, or reason surgical opinion was requested.] HISTORY OF PRESENTING ILLNESS: [Write a focused clinical narrative of the current issue including onset, duration, progression, symptoms, functional impact, relevant positives and negatives, prior procedures, prior biopsy or pathology, imaging, treatment already received, multidisciplinary input, and patient concerns only if clearly stated and relevant.] RELEVANT BACKGROUND: [Include only background details relevant to the current consultation or management such as past medical history, past surgical history, medications, allergies, family history, social history, and other contextual details if provided and relevant.] PHYSICAL EXAMINATION AND INVESTIGATIONS: [Document a focused physical exam and relevant investigations explicitly stated in the encounter. Include relevant imaging, pathology, labs, endoscopy, biopsy results, operative findings, or other diagnostic results that affect the consultation.] ASSESSMENT AND PLAN: This is a [age]-year-old [female/male/person] with [relevant background if important] who presents with [main surgical oncology/general surgery issue]. [I reviewed..., I explained..., I outlined..., I discussed..., I encouraged..., I suggested..., I have arranged..., We will plan to..., We will keep you apprised...] [Integrate key details driving decision-making including measurements, imaging findings, pathology results, exam findings, symptom pattern, disease extent, treatment history, operative considerations, oncologic context, uncertainty, and patient priorities when provided.] Plan: - [Specific actionable plan point] - [Specific actionable plan point] - [Specific actionable plan point] It was a pleasure being involved in the care of this patient. We will keep you apprised of our progress. [Physician Name] The patient consented to the use of AI-enabled documentation software for this encounter. This note has been reviewed for accuracy.