"I just don't know where to start"

Introduction

• Date and address – the position of the date can be either above the address or below it. It is normal to leave a blank line space between the date and address.
• In formal letters (what you are writing), it is normal for the date at the start to be written in full form. Numbers and slashes are fine within the body of the letter.
• The test materials are specifically written for the test date each month, so the date to use is also the same date as the test.
• The test date will also be the date of discharge, most recent consultation etc. within the case notes.

Salutation

• Use the shorter form of the recipient’s name as the full name is clearly stated above in the address.
• This can be followed by a comma.

Subject

• The subject is a place where information such as the name and D.O.B. of the patient can be included.
• Never forget this........ever!

Contents of introductory sentences

• Background information such as name, age, occupation, marital status and gender of the patient if relevant and not mentioned in the subject line.
• A brief summary of the chief complaint, purpose of writing or your primary concern.
• It will usually be only 1-2 sentences long and straight to the point - so the person receiving the letter knows what they are reading.
• Detailed information about the patient’s history and condition should go in the main body of the letter.

Body Paragraphs of the Letter

• Most referral or discharge letters will contain three body paragraphs, and each of the paragraphs should have a main idea which the writer needs to convey to the reader. All the sentences within the paragraphs must relate to this main idea.
• Each paragraph will have a topic sentence - which introduces the reader to the main idea of the paragraph. Identifying or summarising an area of concern regarding the patient.
• Next are the supporting sentences which contain the information regarding patient history, details of symptoms, relevant aspects fro the treatment record, causes and effects, trends etc.Paragraph Structure
• Don't use too many abbreviations, but make sure you use adequate medical terminology if you are writing to another Health Care Professional.

Conclusion of the Letter

• It should be based on the task question, which is found mostly at the end of the case notes.
• It may contain one or two of the following points:

1. a polite request of action required/ a thank you for ongoing support
2. an offer of future assistance if required (this may be useful if you plan to omit some details from the case notes.

1. Could you please examine and treat the patient as you feel appropriate.
2. I hope you can arrange someone to help this family and provide the appropriate services.
3. I would be grateful if you could examine, diagnose and treat the patient as you feel appropriate.
4. I would appreciate if you could examine, diagnose and treat the patient.

Conditional Sentences

• These sentences are also frequently used in the conclusion of a referral, transfer or discharge letter

1. If you have any queries, please do not hesitate to contact me.
2. If you require any more information, please do not hesitate to contact me.
3. If you have any further questions, please do not hesitate to contact me.
4. Please do not hesitate to contact me if you have any further questions.

Closer, Name and Designation

• Leave a space between the last line of the conclusion and the closer.
• The closer should be followed by a comma.
• Then write your name and designation below the closer

General Tips

• Don't rush the process. Read the task first. This will be at the bottom of the page. You need to know who you are writing too, and what you will be writing about.
• After becoming clear on the task, move down the case notes and figure out which information is needed, which might be useful, which information doesn't need to be included. For the last one, put a line through it.
• Formulate a plan - know how you are going to present the information so it is clear and concise. For some letters that will mean combining numerous visits. For others it will be showing a progression of symptoms or treatment over time.
• The best tip - imagine you are the Health Professional getting the letter. Figure out what information you need to be able to take over the care of the patient in a confident and safe manner.