Workflow: Preparing a Pre-Clinic Case Brief from Your Own Notes

Complex patients with multi-system involvement — a combination of pituitary pathology, long-standing diabetes, and cardiovascular risk, for example — can have histories that span years of letters and results. This workflow helps you use AI to reorganise your own previous documentation into a structured brief, so you walk into the appointment prepared rather than scanning back through the file in real time.

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Step 1: Decide What You Need in the Brief

Think about what a useful one-page summary looks like for you. A common structure for endocrinology review: active diagnoses, relevant history (brief), current treatment approach (by type, not specific doses), outstanding investigations or results, and the questions you want to address today.

You may want to add specific sections relevant to the case — recent imaging findings, for example, or pending genetics results.

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Step 2: Find Your Previous Correspondence

Locate any clinic letters, referral letters, or structured notes you have written for this patient. Your own letters are the safest source to use: they are already in your clinical writing style, and they typically contain the information most relevant to your ongoing management.

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Step 3: Anonymise Before Pasting

This step is essential. Before pasting any text into an AI tool, go through it and remove or replace every piece of identifying information:

• Patient name → replace with "Patient" or a general descriptor ("48-year-old woman")
• Date of birth → remove or replace with approximate age
• NHS or hospital number → remove entirely
• GP name and practice → remove
• Any address or postcode → remove

Work through the text systematically. It takes about two minutes for a typical letter. Do not skip this step.

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Step 4: Open Your AI Tool

Open Claude, ChatGPT, or your organisation's approved AI tool. Paste the anonymised text into the conversation window, but do not send it yet.

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Step 5: Write Your Instruction Above the Text

Before the clinical text, write a clear instruction. For example:

"Below is an anonymised clinical summary from my previous correspondence with a patient. Please reorganise this into a structured pre-consultation brief with these five sections: 1. Active diagnoses, 2. Relevant history (brief bullet points), 3. Current treatment approach (describe by type, not specific drug names or doses), 4. Outstanding investigations, 5. Questions to address today. Use bullet points throughout. Do not add any information that is not in the text below."

Then paste your anonymised clinical text after this instruction, and send.

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Step 6: Review the Output Carefully

Read the AI's structured brief against your original text. Check for:

• Anything the AI has included that was not in your original text (remove anything invented)
• Anything important the AI has missed (add it manually)
• Any incorrect reorganisation of information (for example, something presented as a current diagnosis that was actually a historical finding)

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Step 7: Add the Outstanding Questions Yourself

The AI cannot know what specific questions you want to address today — it can only infer from the history. Manually add the key questions you want to answer in the consultation. For example: "Review imaging follow-up plan for adrenal incidentaloma" or "Discuss patient's concerns about weight gain since medication change."

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Step 8: Use the Brief in Clinic

Print or have the brief on screen before you see the patient. You do not need to share it with the patient. It is your preparation tool.

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Step 9: After the Appointment, Update Your Records Normally

The brief is an aide-memoire, not a clinical document. Your consultation note, clinic letter, or other formal documentation should be written and stored in your clinical system as usual. The AI brief is not a substitute for proper record-keeping.

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Remember: AI is a helpful assistant, not a clinician. You make the call.