THROMBOSIS CONSULT ANNA (NEW)

OVERALL_INSTRUCTIONS

CONSULT HEADER: (At the very top of the consult note, reproduce the header information in the exact sequence and structure below. Do NOT reorder fields. Do NOT omit fields if available. Use plain text only.) [DATE] [REFERRING_PHYSICIAN_NAME] [REFERRING_PHYSICIAN_CITY_PROVINCE] Phone: [REFERRING_PHYSICIAN_PHONE] Fax: [REFERRING_PHYSICIAN_FAX] Patient: [PATIENT_FULL_NAME] PHN: [PATIENT_PHN] Birthdate: [PATIENT_DOB] Address: [PATIENT_FULL_ADDRESS] Phone Number: H: [PATIENT_HOME_PHONE] C: [PATIENT_CELL_PHONE] Family Physician: [FAMILY_PHYSICIAN_NAME] [FAMILY_PHYSICIAN_BILLING_OR_ID] (Insert a horizontal divider line after the header.) (Do not move, condense, or paraphrase header information into narrative text.) (If any header field is unavailable, leave the field blank rather than inferring.) Use formal medical terminology only (e.g., DVT, PE, anticoagulation, venous thromboembolism). Do NOT use patient-friendly terms such as “blood clot” or “blood thinner.” Address patients using title + last name only. Do NOT summarize any patient history. Document all dates, symptoms, and events exactly as provided. Maintain a fully chronological, detailed thrombosis history. Never omit ED visits, symptom onset, treatment initiation, or progression details. HISTORY OF PRESENTING ILLNESS: Document the HPI as a chronological, fully detailed narrative. You must include ALL of the following elements exactly as dictated: First symptoms: date + nature of symptoms Symptom progression: how symptoms changed over time All ED/clinic visits: date, reason, assessments done, imaging or lack thereof Diagnosis: date + imaging modality Anticoagulation initiation: drug name, dose, and date Current symptoms: degree of improvement, persistent symptoms, functional impact Any information relevant for medicolegal or work-compensation purposes Do NOT summarize or omit any details. Do NOT alter chronology. Do NOT replace formal medical language with patient language. When options are provided in brackets [ ], choose ONLY the option that matches the dictation and delete the others. Do NOT retain all options. Use formal medical terminology only (e.g., DVT, PE, anticoagulation, venous thromboembolism). Convert any patient-friendly terms captured in the conversation (e.g., “blood clot,” “blood thinner”) into correct medical language. Address patients using title and last name only. Do NOT summarize or compress the clinical history. Extract and document all dates, symptoms, and events exactly as stated by the patient or clinician. Reconstruct a fully chronological thrombosis history even if the conversation provides information out of order. Include ALL of the following elements when present in the conversation: – first symptoms (with dates) – symptom progression – all ED or clinic visits (with dates and assessments) – imaging performed or not performed – date of formal diagnosis – anticoagulant name, dose, and start date – treatment changes – symptom evolution and current status Never omit or generalize any clinical details relevant to thrombosis. If information is missing, leave placeholders but do NOT invent content. [END_OF_NOTE_PADDING] (Insert 3–4 blank lines at the end of the document to prevent PDF truncation.) (Output plain text only.) (PDF SAFETY RULES: - Ensure sufficient bottom margin. - Insert blank-line padding at end of document. - Do not truncate final sentences. - If content approaches page limit, shorten earlier paragraphs, not the final lines.)

Chief Complaint

[Insert chief complaint or reason for referral]

Template

Dear Dr. [Referring Physician], [Title]. [Patient Last Name] was assessed in the Virtual Thrombosis Clinic on [Consult Date]. [Title]. [Patient Last Name] provided consent for both telehealth and AI-assisted clinical documentation. In support of workflow efficiency, the key elements of today’s assessment and plan are summarized below. The comprehensive consult narrative is included thereafter. SUMMARY OF ASSESSMENT: [Title]. [Patient Last Name] is diagnosed with [provoked | unprovoked] [RIGHT-sided DVT | Left-sided DVT | bilateral DVT | bilateral PE | right-sided PE | Left-sided PE | DVT and PE | Cancer-Associated DVT | Cancer-Associated PE | Cancer-Associated DVT and PE] on [Insert Date]. [Title]. [Patient Name] is [anticoagulated | thromboprophylaxed] with [Apixaban 5mg BID | Apixaban 2.5mg BID | Rivaroxaban 20mg daily | Rivaroxaban 10mg daily | Rivaroxaban 2.5mg BID | warfarin target INR 2.0 - 3.0]. Anticoagulation is tolerated well with no evidence of major or clinically relevant bleeding. There is no evidence of recurrent venous thrombosis. SUMMARY OF PLAN: (Insert current anticoagulant, dose, and date of initiation if available. Do NOT summarize past treatments here. Do NOT add any interpretation or reasoning) Anticoagulant: [Apixaban 5mg BID | Apixaban 2.5mg BID | Rivaroxaban 20mg daily | Rivaroxaban 10mg daily | Rivaroxaban 2.5mg BID]. Duration: [3 months | at least 6 months then will be reassessed | Indefinite unless major bleeding complications arise] INVESTIGATIONS: [select one of the following based on the encounter transcript, if none are applicable omit this section] - (No further investigations required. Hypercoagulable work up or repeat US is not indicated as it does not change management. OR - I have requested a repeat US through my office. No further coordination is needed from Dr. [Referring Physician]'s office. OR - I have requested a repeat CTPA through my office. No further coordination is needed from Dr. [Referring Physician]'s office OR - Further work up requested as follows: [Insert details]) FOLLOW-UP: [Title]. [Patient Last Name] is booked for virtual follow up on [Insert Date]. THROMBOSIS HISTORY: [Insert details](point form based on most recent date CURRENT AC TREATMENT: [Insert details] (only insert current anticoagulant and dosage and date of initiation, if available)(do not enter any other details) HISTORY OF PRESENTING ILLNESS: I have the pleasure of assessing [Title]. [Patient Last Name], a [Age] year old [Gender]. diagnosed with [insert current thrombosis diagnosis and date]. [ Insert previous thrombsis history ] [insert currenct thrombosis history collected during this encounter] (make history descriptive, detailed and temporal. Break into few short paragraphs for visual clarity) [Insert relevant negatives: e.g., There is no chest pain, shortness of breath, hemoptysis or syncope.] [Insert relevant negatives: e.g., There is no leg pain or swelling.] [Insert relevant negatives: e.g., There is no recent surgery, trauma or immobility. No estrogen use. The review of system is negative with no constitutional symptoms.] Medication adherence is [excellent. | suboptimal.] [Insert relevant negatives: e.g., The patient denies hemoptysis, hematemesis, bright red blood per rectum, epistaxis or hematuria.] There is no chest pain, shortness of breath, leg pain or swelling. There is no recent surgery, trauma or immobility. No estrogen use. The review of system is negative with no constitutional symptoms. Medication adherence is excellent. The patient denies any clinically significant bleeding history including hemoptysis, hematemesis, bright red blood per rectum, epistaxis or hematuria. REVIEW OF SYSTEMS: - Constitutional: [if no concerns insert "No fevers, chills, sweats, or weight loss", if any issues present, insert relevant findings.] - CNS: [if no concerns insert "No visual changes, no headache, no new neurological symptoms" if any issues present, insert relevant findings.]. - Cardiovascular: [if no concerns insert "No chest pain, palpitations, pre-syncope, or syncope", if any issues present, insert relevant findings.] - Respiratory: [if no concerns insert "No shortness of breath, cough, hemoptysis, or pleuritic chest pain" if any issues present, insert relevant findings.] - Gastrointestinal: [if no concerns insert " Absence of appetite changes, no nausea, vomiting, abdominal pain, diarrhea, constipation or change to bowel habits or stool shape"., if any issues present, insert relevant findings.] - Genitourinary: [if no concerns insert " No hematuria, no dysuria, no nocturia, no retention.", if any issues present, insert relevant findings.] - Derm: [if no concerns insert "No new rashes, no new petechiae or purpura" ., if any issues present, insert relevant findings.] - MSK: [if no concerns insert "No new joint pain, or bony pain"., if any issues present, insert relevant findings.] PMHX: [Insert details] MEDICATIONS: [Insert details] ALLERGIES: [Insert details] REVIEW OF AGE-APPROPRIATE MALIGNANCY: (do not insert if no details available) [Insert details] PHYSICAL EXAMINATION: Patient's self-reported: (if no reported weight or height delete this section) - Body weight: [Insert value] kg - Height: [Insert value] Physical examination was deferred due to the telehealth nature of this consultation. (always insert this section on tele health consults) LABORATORY INVESTIGATIONS: [Insert details] HYPERCOAGULABLE WORKUP: [Insert details] THROMBOSIS IMAGING: [Insert details] IMPRESSION: [insert impression]. [Provide a formal thrombosis-focused impression based solely on information from the encounter. Do NOT include family history. Do NOT add unrelated diagnoses.] PLAN: [PLAN_SUMMARY_PARAGRAPH] (Write a single formal paragraph summarizing today’s management plan in complete sentences. Include: anticoagulant name + dose + duration/next step; key rationale; follow-up testing; follow-up interval. Do NOT use bullet points in this paragraph. Do NOT add new information that was not stated in the encounter.) [PLAN_BULLETS] (Then list the plan as numbered bullet points. Each bullet begins with a verb. Keep items concise and action-oriented. If a plan item is not addressed today, do not include it.) [PLAN_SUMMARY_PARAGRAPH] (Use the same tone as a specialist thrombosis consult letter. Avoid patient-friendly terms. Use DVT/PE/CTPA/VQ/US. No speculation. No generic safety-net unless discussed.) 1. [Insert plan details] [Title]. [Patient Last Name] has tolerated anticoagulation well with no evidence of bleeding. Venous thrombosis symptoms present at the time of the presentation have improved. [Title]. [Patient Last Name] continues to be a good candidate for DOAC. The renal function is stable. There is no evidence of hepatic impairment. There are no drug-drug interactions. 2.DISCUSSION / COUNSELLING: [COUNSELLING_MODULES] (Only include modules that were explicitly discussed during today’s encounter. If a topic was not discussed, omit that module entirely.) Then add modules like these: 1) High-risk sports / trauma risk module (skiing, contact sports, etc.) [COUNSELLING_HIGH_RISK_ACTIVITY] (Include ONLY if clinician counselled on high-risk activity/sports while anticoagulated. Individualize to the patient’s stated activities (e.g., skiing, hockey, mountain biking). Write 3–5 sentences in formal tone. Include: rationale (trauma/bleeding risk on anticoagulation), specific examples relevant to patient, safer alternatives if mentioned, and what to do if trauma/head injury occurs if discussed. Do not over-warn; keep proportional.) Spoken anchor for you (one-liner): “Counselling: anticoagulation and high-risk activity — we discussed avoiding [skiing/hockey/etc.] while anticoagulated.” I provided the patient with education on the importance of taking the anticoagulant consistently and what to do if [he/she] misses a dose. I recommend holding [Insert anticoagulant] for 2 full days prior to any invasive procedure or surgery. Post-procedural resumption of anticoagulation will depend on postoperative risk of bleeding. If there are any questions or concerns about periprocedural management of anticoagulation, please feel free to contact me. We also discussed strategies to mitigate the risks of bleeding. The patient is not on any non-essential antiplatelet agent or NSAIDS. I recommend avoiding high-risk behaviors such as excess alcohol use or extreme sports. 3.) Missed dose / adherence module [COUNSELLING_ADHERENCE_MISSED_DOSE] (Include ONLY if adherence or missed-dose instructions were discussed. Summarize instructions provided (what to do if a dose is missed) and reinforce consistent dosing.) Spoken anchor: “Counselling: adherence and missed-dose plan.” 4.4) Bleeding red flags / ER precautions module [COUNSELLING_BLEEDING_PRECAUTIONS] (Include ONLY if bleeding precautions were discussed. Individualize to what was emphasized (e.g., hematuria with clots, GI bleeding, head injury). Keep to 2–4 sentences.) Spoken anchor: “Counselling: bleeding precautions and when to present to ER.” The patient should go to the emergency department if there is a concern for recurrent venous thromboembolism or bleeding. The signs and symptoms of DVT, PE and bleeding were reviewed with the patient today. Thank you for the opportunity to be involved in their care. Please don’t hesitate to contact me if you have any questions or concerns. Sincerely, Anna Rahmani MD PhD FRCPC *THIS REPORT WAS GENERATED BY A SPEECH RECOGNITION SYSTEM AND MAY CONTAIN TYPOGRAPHICAL OR GRAMMATICAL ERRORS. IF THIS REPORT IS UNCLEAR OR IF THERE IS ANY CONCERN REGARDING THE CONTENT, PLEASE CONTACT THE AUTHOR FOR CLARIFICATION.* List of Abbreviations: AC: Anticoagulation | CTPA: CT Pulmonary Angiogram | DVT: Deep Vein Thrombosis | PE: Pulmonary Embolism | US: Ultrasound | PTS: Post Thrombotic Syndrome [END_OF_NOTE_PADDING]