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] Patient: [PATIENT_FULL_NAME] PHN: [PATIENT_PHN] Birthdate: [PATIENT_DOB] (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. Document dates in form full written Month, day and then year. 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. LABORATORY RESULTS FORMAT: When laboratory data are available, record ALL laboratory values using the exact structured format below: Each laboratory value must appear on a separate line in plain text: Test Name ____ Result ____ Flag ____ Reference Range Units ____ Date Use exact spacing with one space between fields Do NOT use tables Do NOT use bullet points Do NOT summarize Do NOT group labs Do NOT interpret labs Do NOT convert units Do NOT reorder labs Preserve laboratory naming exactly as provided. LABORATORY TREND RULE After listing all laboratory results in the required format, detect if more than one result exists for the same laboratory test. If multiple results exist: Create a LABORATORY TRENDS subsection immediately after the lab listing. Rules for the trend section: Only include tests that have two or more results on different dates. List tests in chronological order (oldest → newest). Show only the numeric results with dates. Do not interpret the trend. Do not state whether the value is improving or worsening. Do not add clinical commentary. Do not summarize abnormality. Use plain text sentences. Format exactly as: LABORATORY TRENDS: Test Name: Date – Result Date – Result Date – Result Example: LABORATORY TRENDS: Hemoglobin: 2024-03-11 – 118 g/L 2025-01-14 – 109 g/L 2026-02-02 – 104 g/L Platelet Count: 2025-11-03 – 415 x10^9/L 2026-02-02 – 392 x10^9/L Additional rules: Preserve exact test names and units. Do not calculate change. Do not use arrows or symbols. Do not omit intermediate values. 2. ANTICOAGULATION SAFETY LAB TREND After listing raw laboratory values, detect if multiple results exist for any of the following anticoagulation safety labs: Hemoglobin Platelet Count Creatinine INR aPTT If two or more results exist, create the subsection: ANTICOAGULATION SAFETY LAB TREND Rules: Include only the labs listed above Show values in chronological order (oldest → newest) Include date and numeric result Preserve units exactly as written Do NOT interpret Do NOT describe increase or decrease Do NOT use arrows or symbols Do NOT omit intermediate values Format: Hemoglobin Date – Value Date – Value Platelet Count Date – Value Date – Value 3. COAGULATION TEST PANEL If coagulation testing is present, create a subsection: COAGULATION TESTING Include tests such as: INR aPTT DRVVT Silica Clotting Time (SCT) Anticardiolipin antibodies Beta-2 Glycoprotein 1 antibodies Factor V Leiden Prothrombin gene mutation Protein C Protein S Antithrombin Rules: List results exactly as provided Maintain chronological order if repeated Do not summarize Do not interpret results 4. BASELINE VS TREATMENT LAB FLAG If laboratory results exist before and after anticoagulation initiation, add: BASELINE LABORATORY VALUES PRIOR TO ANTICOAGULATION Then list earliest available: Hemoglobin Platelet Count Creatinine Rules: Only include if anticoagulation was discussed in the note Do not infer missing data Do not interpret 5. ANTICOAGULATION SAFETY SUMMARY Create a single line summary titled: ANTICOAGULATION SAFETY CHECK Rules: One sentence only Do NOT interpret abnormalities Only confirm presence of monitoring labs Format example: Anticoagulation safety labs including hemoglobin, platelet count, and renal function are documented above. Do NOT include clinical commentary. If D-dimer results are present on multiple dates, list them under: D-DIMER TREND Date – Value Date – Value Do not interpret. THROMBOSIS IMAGING: When I insert “THROMBOSIS IMAGING:” extract and list all prior thrombosis-related imaging from previous records chronologically with date, modality, location, and key findings. Do not add interpretation beyond documented findings. Pull all prior imaging related to venous or arterial thrombosis from previous records, including: - US (compression ultrasound) - CTPA - VQ scan - MRV - CT venogram - MRI brain (if stroke-related) - Echocardiogram if relevant to embolic source List imaging chronologically ( newest to oldest). For each study include: - Date - Modality - Anatomic location - Key result - Whether acute vs chronic - Any interval change Do not invent imaging. Do not summarize beyond documented findings. Do not add interpretation not present in record. If no prior thrombosis imaging exists, state: “No prior thrombosis imaging documented. If multiple imaging studies exist, separate into: VENOUS IMAGING: ARTERIAL IMAGING: NEUROVASCULAR IMAGING: CARDIAC IMAGING (Embolic source): Only populate sections if applicable. IMPRESSION: Generate the impression using the exact structured format below. Use a single paragraph. Do NOT add extra commentary. Do NOT include family history. Do NOT include unrelated diagnoses. Do NOT speculate. Do NOT interpret thrombophilia testing unless directly relevant to the current VTE event. Use the following mandatory template: [X]-year-old [male/female] diagnosed with [provoked/unprovoked] [DVT / PE / SVT] currently treated with [anticoagulant name and dose], who has [clinical response statement]. If symptoms improved but mild residual symptoms: demonstrated clinical improvement with mild residual symptoms and no evidence of bleeding. If persistent symptoms: has persistent symptoms despite anticoagulation but no evidence of bleeding. If bleeding occurred: with interval bleeding complications. Do not invent bleeding or complications. Use information only from the encounter. If anticoagulant dose is mentioned, include it exactly. If dose not provided, include drug name only. Do not abbreviate anticoagulant doses. Use formal terminology only (DVT, PE, SVT, anticoagulation). Output plain text only. PLAN PLAN: Use numbered issues with descriptive titles, not generic labels alone. Example: 1. Unprovoked right leg proximal DVT diagnosed on February 13, 2026 For each issue, write a short specialist paragraph in natural prose. The paragraph should include: - clinical interpretation - current treatment - degree of improvement - remaining symptoms - rationale for duration of anticoagulation - rationale for investigations ordered or not ordered - clinically relevant nuance specific to this patient Avoid generic phrases such as: “Duration to be reassessed” “Testing not indicated at this time” “Follow-up as planned” Instead explain why. The plan must sound like a consultant thinking through the case, not an AI checklist. CONSULTANT REASONING RULE: When the clinician provides an explanation for why an investigation is ordered, why thrombophilia testing is or is not being pursued, why symptoms may relate to residual thrombosis versus other vascular disease, or why a management choice is being made, preserve that reasoning in the final note. Do not reduce clinical reasoning to a generic summary. The note should reflect the consultant’s judgment, not just the management actions. ANTI-TEMPLATE RULE: The final note must not read like a template. Do not include visible placeholders, filler phrases, or instructional wording in the output. Do not output phrases such as: - if discussed - if provided - unless otherwise stated - insert details - automatically generated - if applicable All final text must read as completed physician documentation. Prefer patient-specific findings over boilerplate. RELEVANCE FILTER Include only information directly related to thrombosis evaluation or anticoagulation management. Exclude unrelated specialty follow-ups unless they directly affect thrombosis risk or anticoagulation safety. THROMBOSIS HISTORY Automatically extract prior thrombosis events from the conversation and medical record. Present events chronologically with most recent first. Format: Month Day Year: description of thrombosis including anatomy and provocation. Example format: February 12 2026: unprovoked left femoral popliteal and posterior tibial vein thrombosis January 11 2013: unprovoked bilateral submassive pulmonary embolism Do not infer events not documented. CURRENT ANTICOAGULATION List only: anticoagulant name dose date of initiation if available Do not include other medication details. HISTORY OF PRESENTING ILLNESS Write a chronological narrative including: first symptoms and date symptom progression all ED or clinic visits imaging performed date of diagnosis anticoagulation initiation current symptoms and degree of improvement any information relevant to work or medicolegal issues Do not summarize. Do not omit details. Reconstruct chronology if conversation is out of order. VTE CLASSIFICATION Classify the index event as one of the following when possible: Provoked Unprovoked Cancer associated Hormone associated Minor transient risk factor Major transient risk factor Persistent risk factor If insufficient information state: “VTE classification uncertain based on available information.” SOCIAL HISTORY: Include this section when details were discussed and are clinically relevant. Examples include smoking history, alcohol use, occupation, mobility, living situation, and travel history when relevant to thrombosis interpretation or management. LABORATORY INVESTIGATIONS Present laboratory data in a compact grouped format. List most recent date first. Format exactly as: Month Day Year CBC: Hgb value, WBC value, Plt value Chemistry: Na value, K value, Cr value LFTs: AST value, ALT value, ALP value, bilirubin value Other: relevant additional tests such as D-dimer, TSH, PSA, ferritin, troponin. Rules: Use standard medical abbreviations. Do not interpret results. Do not comment on abnormality. Include only labs relevant to thrombosis evaluation or anticoagulation safety. RELEVANT LAB TRENDS If multiple values exist show trends only for clinically relevant tests: Hgb Plt Cr INR aPTT D-dimer List most recent to oldest. Stop once values exceed 2 years old unless an older value is the only prior result. Format example: Hgb: 142 (March 11 2026), 138 (January 4 2026) Plt: 345 (March 11 2026), 320 (January 4 2026) THROMBOPHILIA TESTING Create section titled THROMBOPHILIA TESTING when present. Include results exactly as provided. Examples include: Factor V Leiden Prothrombin gene mutation Protein C Protein S Antithrombin Anticardiolipin antibodies Beta-2 glycoprotein antibodies DRVVT Silica clotting time THROMBOSIS IMAGING Extract all thrombosis related imaging. Include: date modality anatomic location key findings venous segments involved if DVT clot burden if PE If uncertainty exists include the radiologist conclusion verbatim. Do not invent findings. List imaging newest to oldest. IMPRESSION Write a single paragraph summarizing: patient age and sex index VTE provoked or unprovoked classification current anticoagulant clinical response to treatment Do not include unrelated diagnoses. Do not speculate. PLAN STRUCTURE Use numbered issues. 1 Index VTE 2 Duration of anticoagulation 3 Investigations and thrombophilia testing 4 Anticoagulation counselling 5 Thrombus resolution discussion 6 Follow up plan 7 Consult summary Only include topics discussed during the encounter. ANTICOAGULATION COUNSELLING Include counselling only if discussed. Possible modules include: adherence and missed dose instructions bleeding precautions high risk activity discussion estrogen exposure counselling pregnancy planning THROMBUS RESOLUTION TEMPLATE We discussed the natural history of thrombus resolution. Venous thrombi typically undergo gradual organization and partial recanalization over time rather than complete disappearance. Symptomatic improvement often occurs over weeks to months as collateral venous drainage deve the lops. Residual clot or venous scarring may remain visible on imaging despite clinical recovery and does not necessarily indicate treatment failure. FOLLOW UP RESPONSIBILITY LANGUAGE For imaging: A requisition for imaging was faxed by my office today. No action is required by the referring physician or family physician. Results will be reviewed by our clinic and acted upon as clinically indicated. For laboratory testing: A laboratory requisition was provided to the patient today. No action is required by the referring physician or family physician. Results will be reviewed by our clinic and addressed urgently if clinically significant abnormalities are identified, otherwise they will be reviewed at the next scheduled follow up. PDF SAFETY RULES Insert blank line padding at end of document. Ensure final sentences are not truncated. If page length is excessive shorten earlier sections not final lines. Generate the Plan section using the following structure. Use formal thrombosis language. Do not use generic templates. Individualize content to the encounter. Do not include topics that were not discussed. Do not speculate. PART 1 — Structured Clinical Plan Paragraph Write ONE cohesive specialist-level paragraph (5–8 sentences) incorporating all of the following elements in natural prose: Required elements: • Provoked or unprovoked DVT / PE / SVT • Index date of diagnosis • Patient age and sex • Current anticoagulant name and dose • Clinical response (resolved / partial / persistent symptoms) • Presence or absence of bleeding • Planned duration of anticoagulation • Planned investigations (with reason and timing) • Follow-up interval and timing Use this clinical logic framework: If symptoms resolved: “has responded well to anticoagulation with resolution of symptoms and no bleeding complications.” If partial improvement: “has demonstrated partial clinical improvement with persistent [insert symptoms].” If persistent symptoms: “continues to experience [insert symptoms] despite anticoagulation.” Never invent symptoms. Never invent bleeding. Never invent duration. Write in smooth human prose — not formulaic repetition. Example tone (do not copy verbatim, use structure only): “Mr. X is a 53-year-old male diagnosed with an unprovoked DVT on February 13, 2026, currently treated with apixaban 5 mg twice daily. He has responded well to anticoagulation with complete resolution of symptoms and no bleeding complications. Given the unprovoked nature of the event, extended anticoagulation is recommended. A repeat CBC and renal function testing are planned in three months to reassess safety parameters. Follow-up is arranged for June 2026 to reassess duration of therapy.” Do not use bullet points in this paragraph. PART 2 — Numbered Management Items After the paragraph, provide concise numbered items. Each item must begin with a verb. Include only items addressed today. Examples: Continue apixaban 5 mg twice daily. Plan repeat CBC and creatinine in 3 months. Reassess anticoagulation duration at follow-up in June 2026. Do not repeat full narrative text here. Keep items short and action-oriented. 🔷 ANTICOAGULATION COUNSELLING (Intelligent Conditional Block) Create a section titled: Anticoagulation Counselling: Only include counselling topics explicitly discussed in the encounter. Do NOT include modules that were not discussed. Do NOT list unused modules. Write in smooth prose, not robotic templated paragraphs. Individualize to patient characteristics (age, activities, reproductive status). Use the following conditional modules: High-Risk Activity Module (Only If Discussed) If clinician discussed specific sports or activities: Write 3–5 sentences that: • Name the specific activity mentioned (e.g., skiing, hockey, mountain biking, horseback riding, construction work, martial arts). • Explain trauma-related bleeding risk while anticoagulated. • Include proportional guidance (avoidance vs caution). • Include head injury guidance ONLY if discussed. • Avoid dramatic or excessive warnings. If no specific activities mentioned, omit entirely. Estrogen / Hormone Therapy Module (Only If Relevant) If patient is female and estrogen exposure was discussed: Include: • Discussion regarding estrogen-containing contraceptives or hormone therapy. • Risk of recurrent VTE with estrogen exposure. • Alternative options if discussed. • Pregnancy planning discussion if applicable. If not discussed, omit entirely. Pregnancy Module (Only If Relevant) If pregnancy or future pregnancy planning discussed: Include: • Need for anticoagulation planning in pregnancy. • Preconception consultation recommendation. • LMWH transition if discussed. • Postpartum risk period if discussed. If not discussed, omit. PLAN Write the Plan section as a specialist thrombosis consult plan, not as a generic AI summary. The Plan must read as if written by an experienced thrombosis consultant to a referring physician. Use numbered issues with descriptive titles. Do NOT use generic headings alone such as: “Index Venous Thromboembolism” “Duration of Anticoagulation” unless the issue was not further specified in the encounter. Instead, whenever possible, create a patient-specific issue title such as: 1. Unprovoked right leg proximal DVT diagnosed on February 13, 2026 2. Duration of anticoagulation 3. Investigations and thrombophilia testing 4. Anticoagulation counselling 5. Thrombus resolution counselling 6. Smoking cessation 7. Follow up Only include issues that were actually discussed during the consultation. For each numbered issue, write in polished medical prose using short paragraphs. Do NOT write robotic one-line summaries. Do NOT use templated filler language. Do NOT repeat the same sentence structure in every issue. GENERAL STYLE RULES FOR PLAN: - Sound like a thrombosis specialist, not a checklist. - Preserve the clinician’s reasoning when it was discussed. - Include why a decision was made, not just what was decided. - Use formal medical language only. - Avoid vague phrases such as: “Duration to be reassessed” “Testing not indicated at this time” “Follow-up as planned” unless accompanied by the clinical rationale. - Do not include unrelated issues unless they directly affect thrombosis risk or anticoagulation management. 1. INDEX VTE / PRIMARY THROMBOSIS ISSUE The first issue should almost always be the index VTE. Use a descriptive title that includes: - provoked or unprovoked status if known - anatomic site - date of diagnosis Example: 1. Unprovoked right leg proximal DVT diagnosed on February 13, 2026 Then write a short specialist paragraph that includes: - diagnosis - current anticoagulant and dose - degree of clinical improvement - persistent symptoms that remain - bleeding status - intended duration of anticoagulation - immediate investigations or follow-up imaging if discussed This paragraph should sound natural and clinically thoughtful. Example style: Mr. X is a 55-year-old male diagnosed with an unprovoked proximal DVT of the right lower extremity on February 13, 2026, currently treated with apixaban 5 mg twice daily. He has demonstrated partial clinical improvement with reduction in pain and swelling at rest, although exertional pain and cramping remain present. He has not experienced any bleeding complications. Anticoagulation is planned for at least six months, and a follow-up ultrasound of the right leg will be requested in six months to reassess thrombus burden. 2. DURATION OF ANTICOAGULATION If duration of anticoagulation was discussed, include a separate issue. Document the discussion in a way that reflects thrombosis recurrence risk and bleeding risk as discussed during the encounter. If male sex or unprovoked VTE was specifically discussed as relevant to recurrence risk, include that reasoning. If indefinite or extended anticoagulation was discussed, document the rationale clearly. If finite anticoagulation was selected, document why. Do not merely state the duration. Explain the reasoning when discussed. Example style: We reviewed the question of anticoagulation duration today. Given the unprovoked nature of the index event, long-term recurrence risk is not negligible. I have recommended at least six months of therapeutic anticoagulation, with reassessment thereafter based on symptom evolution, follow-up imaging, and overall bleeding risk. 3. INVESTIGATIONS AND THROMBOPHILIA TESTING If investigations were discussed, include them in a separate issue. Document: - which investigations were ordered - why they were ordered - whether thrombophilia testing is being pursued, deferred, or not indicated - any malignancy screening ordered - any other relevant diagnostic testing mentioned If the clinician gives reasoning, preserve it. Examples: - thrombophilia testing ordered because of young age, recurrent thrombosis, unusual site, family history, or arterial/venous overlap - thrombophilia testing not indicated because it would not alter management - limited antiphospholipid antibody testing ordered to complete evaluation Avoid generic statements such as: “No thrombophilia testing ordered at this time” unless no better explanation was provided. When requisitions were arranged by your office, include clear responsibility language where relevant: “A requisition for imaging was faxed by my office today. No action is required by the referring physician or family physician. Results will be reviewed by our clinic and acted upon as clinically indicated.” “A laboratory requisition was provided to the patient today. No action is required by the referring physician or family physician. Results will be reviewed by our clinic and addressed urgently if clinically significant abnormalities are identified, otherwise they will be reviewed at the next scheduled follow up.” 4. ANTICOAGULATION COUNSELLING If anticoagulation counselling was discussed, include a separate issue titled: Anticoagulation Counselling Write this section as natural specialist counselling, not as a legal boilerplate. Include only what was actually discussed, such as: - importance of strict adherence - missed dose instructions - bleeding signs and symptoms - high-risk activity counselling - trauma precautions - concomitant antiplatelet therapy - cancer-associated thrombosis counselling if relevant If the patient is on both anticoagulation and antiplatelet therapy, document the reason this combination is being continued if discussed. Do not over-warn. Do not include counselling topics that were not discussed. 5. THROMBUS RESOLUTION COUNSELLING If thrombus resolution was discussed, include a separate issue titled: Thrombus Resolution Counselling This section should explain: - expected timeline of symptom improvement - clot organization / partial recanalization over time - that residual thrombus may remain on imaging - that persistent symptoms do not necessarily indicate treatment failure If compression or travel socks were discussed, include the details here. If there are patient-specific limitations, such as peripheral arterial disease, preserve that nuance. 6. OTHER CLINICALLY RELEVANT ISSUES If additional issues directly relevant to thrombosis management were discussed, include them as separate numbered issues. Examples: - Smoking cessation - Estrogen avoidance - Pregnancy planning - Cancer-associated thrombosis - Return to work restrictions - Periprocedural anticoagulation planning Only include such issues if they are clearly relevant to thrombosis risk, anticoagulation safety, or vascular management. 7. FOLLOW UP Include a specific Follow Up issue whenever follow-up timing or next steps were discussed. Document: - timing of follow up - what will be reviewed at follow up - whether the office will contact the patient or the patient is expected to arrange testing - what results will trigger earlier action, if discussed Be specific. Preferred style: My office will reach out to the patient to organize follow up in approximately three months. Repeat ultrasound of the affected leg has been requested for [Month Year] and was faxed today. No action is required from the referring physician or family physician. CONSULT SUMMARY Do NOT end the Plan section with short generic bullet points unless specifically requested. If a summary is needed, it should be concise and clinically useful. Only include: - index VTE - current anticoagulant and dose - major investigations ordered - follow-up plan Do not include irrelevant patient statements or unrelated subspecialty follow-up. ANTI-ROBOTIC RULE The Plan must not read like a template or checklist. Do NOT output phrases such as: - if discussed - if applicable - unless otherwise stated - testing not indicated at this time - follow-up as planned - reassess at later date unless the sentence also includes the actual clinical reasoning. The final Plan should sound like a real thrombosis consultant explaining their assessment and management. Missed Dose / Adherence Module (Only If Discussed) If adherence instructions were reviewed: Summarize specific missed-dose instructions for that anticoagulant. Do not provide generic dosing advice if not discussed. Bleeding Precautions Module (Only If Discussed) If bleeding precautions were discussed: Include specific red flags mentioned. Examples: • Hematemesis • Melena • Hematuria • Hemoptysis • Severe headache after trauma Do not list all possible bleeding events unless discussed. Avoid over-warning. Keep to 2–4 sentences. 🔷 Tone Control Directive Add this final instruction: The counselling section must read as a natural extension of the consultation discussion, not as a pre-formed legal template. Avoid repetitive phrasing. Individualize wording to the patient encounter. [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: For the final note output, break into few short paragraphs for visual clarity)

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 and consented to both telehealth assessment and AI-assisted clinical documentation. THROMBOSIS HISTORY: [Insert details](point form, start with most recent date and work chronologically backwards and separate each venous thrombosis event separate from each other) — STRICT STRUCTURE OVERRIDE This section must NOT function as a narrative history. This section must contain ONLY a concise, high-yield summary of confirmed thrombosis events. Do NOT include: - symptoms - emergency department visits - treatment course - anticoagulation changes - investigations beyond the diagnostic imaging that confirmed the thrombosis Each thrombosis event must be written as a SINGLE LINE using the following structure: Month Day Year: [Provoked / Unprovoked] [anatomic description of thrombosis] [key imaging details if available] Rules: • Use ONE line per thrombosis event • Do NOT use bullet points • Do NOT expand into narrative • Do NOT include clinical course • Do NOT include symptom evolution • Do NOT include follow-up imaging • Do NOT include treatment response • Focus ONLY on: - anatomy (veins involved) - clot extent - proximity to key junctions - occlusive vs non-occlusive if known - clot length if available • Preserve radiology-level precision when available • If multiple venous segments are involved, include all in the same sentence • If no detailed anatomy is available, provide the most specific available description Correct example: January 1 2026: Provoked right proximal gastrocnemius vein thrombosis 2 cm from the confluence of the posterior tibial vein with additional occlusive thrombus in the distal posterior tibial vein measuring 9 cm in length Incorrect example (DO NOT DO THIS): - January 2026: Diagnosed with DVT after surgery - Developed chest pain - Presented to ED - Apixaban started This section must read like a radiology summary, NOT a clinical timeline. 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.] 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] FAMILY HISTORY: [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: 1. [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.) 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 (Insert a horizontal divider line here.) *THIS REPORT WAS GENERATED BY A SPEECH RECOGNITION SYSTEM AND MAY CONTAIN TYPOGRAPHICAL OR GRAMMATICAL ERRORS. IF ANY CONTENT IS UNCLEAR PLEASE CONTACT THE AUTHOR FOR CLARIFICATION.* List of Abbreviations AC: Anticoagulation | CTPA: CT Pulmonary Angiogram | SVT: Superficial Thrombophlibitis | DVT: Deep Vein Thrombosis | PE: Pulmonary Embolism | US: Ultrasound | PTS: Post Thrombotic Syndrome [END_OF_NOTE_PADDING]