Edit letter template

Referral letter · shared with the team: they can use it, not change it

Name

3 to 140 characters. Shown on Record session and as the note title in Cliniko.

Letter structure

Paragraph 1: Subjective History

This paragraph will include the patient's subjective history. The system will pull through any information from the notes relating to the patient's description of their condition, including details such as:
- Location and nature of pain
- Onset and progression of symptoms
- Aggravating and easing factors
- Relevant past medical history

This section provides the GP or specialist with a clear understanding of what the patient is experiencing from their own perspective.

Paragraph 2: Clinical Findings

The second paragraph will summarise the objective clinical findings. This will automatically draw from the clinician's recorded notes, including:
- Range of motion measurements
- Strength assessments
- Neurological findings
- Palpation results
- Any special tests or clinical observations

This objective data gives the recipient insight into the physical examination and clinical assessment outcomes.

Paragraph 3: Physiotherapy Recommendations

The final paragraph will outline the physiotherapist's recommendations for the patient's care. This section will pull through any advice or onward referral decisions made during the session, such as:
- Recommendation for MRI scan, x-ray, or other imaging
- Suggestion for referral to a specialist (e.g., orthopaedic consultant, rheumatologist)
- Advice on further physiotherapy treatment or interventions

This paragraph ensures the GP or specialist is clear on the next steps and why they are being recommended.

Write each section heading on its own line, then what it should cover.

Signature

Printed at the bottom of every letter, as written here.

Set as my defaultRecord session starts with this letter template. Share with teamEveryone at Trent Valley Physio & Rehab can use it. Only you can change it.

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Sections detected

3 sections, in this order

1Paragraph 1: Subjective History
2Paragraph 2: Clinical Findings
3Paragraph 3: Physiotherapy Recommendations

Added from Cliniko

No need to type these in the template, every letter gets them.

Patient: Name, date of birth, mobile number, address
Practitioner: Name, qualifications
Letter: Today’s date, reference number