A format which will fit most scenarios is as follows:

  • Introduction: Including purpose of writing and chief complaint in brief
  • Body Paragraph 1: Patient past medical history in summary
  • Body Paragraph 2: Trends in history & medication
  • Body Paragraph 3: Chief complaint and current situation in detail
  • Conclusion: Concluding request specific to the task

Structure

  1. Address

    1. Doctor’s name
    2. Specialty
    3. Name of hospital and address
    4. Today’s date
    5. Dear (Doctor’s last name)
    6. Re: (patient’s full name), D.O.B./Age (if DOB not given)
  2. Introduction

    1. Normally two sentences.
    2. Mainly maintain the purpose of referral.
  3. Body Part 1

    1. Personal history/marital status/smoker/alcoholic/profession
    2. Medical history
    3. Medication history
    4. Family history
    5. Allergy history
  4. Body Part 2/Initial Relevant Visit

    1. Complaints & symptoms
    2. Examination finding
    3. Treatment:
      • Prescription
      • Advice
      • Investigation
      • Review schedule
  5. Body Part 3/Subsequent Visit

    1. Condition (improvement/deterioration)/new symptom
    2. Examination finding
    3. Investigation results
    4. Further changes to medication/additional advice/recommendation
  6. Body Part 4 (Final/Today’s Visit)

    1. Final condition
    2. Final investigation findings
    3. Final assessment
    4. Final treatment and plan
  7. Conclusion

    1. In view/light of the above, I believe X is/has been suffering from Y disease.
    2. Your further assessment—include any specific request.
    3. Should there be any queries, please do not hesitate to contact me.
  8. Closing

    • Yours sincerely,
    • Doctor