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
-
Address
- Doctor’s name
- Specialty
- Name of hospital and address
- Today’s date
- Dear (Doctor’s last name)
- Re: (patient’s full name), D.O.B./Age (if DOB not given)
-
Introduction
- Normally two sentences.
- Mainly maintain the purpose of referral.
-
Body Part 1
- Personal history/marital status/smoker/alcoholic/profession
- Medical history
- Medication history
- Family history
- Allergy history
-
Body Part 2/Initial Relevant Visit
- Complaints & symptoms
- Examination finding
- Treatment:
- Prescription
- Advice
- Investigation
- Review schedule
-
Body Part 3/Subsequent Visit
- Condition (improvement/deterioration)/new symptom
- Examination finding
- Investigation results
- Further changes to medication/additional advice/recommendation
-
Body Part 4 (Final/Today’s Visit)
- Final condition
- Final investigation findings
- Final assessment
- Final treatment and plan
-
Conclusion
- In view/light of the above, I believe X is/has been suffering from Y disease.
- Your further assessment—include any specific request.
- Should there be any queries, please do not hesitate to contact me.
-
Closing
- Yours sincerely,
- Doctor