Virtual Thrombosis Clinic Follow up Note

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.) 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 brief statement of patient's presenting issue, e.g., 'Follow-up for venous thromboembolism management']

Template

**VIRTUAL THROMBOSIS CLINIC FOLLOW UP NOTE** Anna Rahmani MD PhD FRCPC _____________________________________________________________________ Dear Dr. [Referring Physician], [Title]. [Patient Last Name] was assessed in the Virtual Thrombosis Clinic on [Follow Up Date]. The patient provided consent for telehealth. [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]. [Gender]. [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: [Title]. [Patient Last Name] will continue with [treatment | thromboprophylaxis] as follows: - 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: - [No further investigations required. Hypercoagulable work up or repeat US is not indicated as it does not change management.] - [I have requested a repeat US through my office. No further coordination is needed from Dr. [Referring Physician]'s office.] - [I have requested a repeat CTPA through my office. No further coordination is needed from Dr. [Referring Physician]'s office.] - [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 relevant history] CURRENT AC TREATMENT: [Insert Relevant History] _____________________________________________________________ INTERVAL HISTORY: [Insert interval history details] PHYSICAL EXAMINATION: Physical examination was deferred due to the telehealth nature of this consultation. LABS: [Insert laboratory results if available] HYPERCOAGULABLE WORKUP: [Insert details if performed] IMAGING: [Insert imaging results if available] IMPRESSION: [Insert clinical impression] **PLAN:** [Insert detailed plan] 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