Writing Notes: The Ideal Letter Should Have 6 Parts

Writing notes
 Time is 45 minutes : 5 minutes reading and 40 minutes writing.

 Number of words should be 180-200 words +/- 10 words.
 Each paragraph should contain at least 2 sentences.
 The diseases are written in full and small letters if composed of one or two words,
ex: diabetes mellitus, gout.
 The diseases are written in abbreviation and capital letters if composed of three
or more words, ex: UTI, URTI.
 Investigations are written in abbreviation and capital letters, ex: CBC.
 Drugs are written capital for trade names, ex: Ventolin.
 Drugs are written small for generic names, ex: paracetamol.
 In short cases, use the long version of introductory and conclusion paragraphs, but
in long cases, the short versions are used.
 Don’t forget to use capital letter after full stops and small letter after commas.
 Avoid too long sentences.
 Avoid mixing tenses in the same paragraph, except body 1.
 Use passive.
 Use formal terms, ex: tell  inform , start  commence.
 Don’t write details in introductory and conclusion paragraphs.
 Use (an) for an X-ray and an MRI.
The ideal letter should have 6 parts :

1. Address.
2. Introductory paragraph.
3. Body 1 : social and medical history.
4. Body 2 : visits.
5. Body 3 : final visit.
6. Conclusion paragraph.
1-Address format:
Dr Sara Adams
Psychiatrist
177 Main Road
Newtown
17/01/2016
Dear Dr Adams,
Re: Mr Jones Walter D.O.B. 07/03/1986
Or
Admitting Officer
123 Second Avenue
Newtown
17/01/2016
Dear Sir/Madam,
Re: Mr Jones Walter , 30 years of age
2- Introductory paragraph :
long introduction:
I am writing this letter to refer Mr Walter, a 30-year-old patient (teacher), who
is presenting with signs and symptoms suggestive of gout. I would be glad if you
could manage his condition as you think appropriate. (38 words)
Short introduction:
Thank you for seeing Mr Walter, a 30-year-old patient (teacher), who is
presenting with features consistent with gout. Your further management is highly
appreciated. (25 words)
Other sentences that can be used in this paragraph:

His condition is getting progressively worse.
His condition is getting much better.
His condition needs your further management.
3- Body 1: (social and medical history )
Ms Adams is married with three children. However she does not smoke, she is a
heavy drinker. Regarding her medical history, she is ……… . Please note, her father
had ………. .
Use present t.
4- Body 2: (different visits)
On 02/12/2016(first visit), the patient initially presented complaining of ……… ;

consequently, blood tests were ordered which unfortunately revealed ……… . A
month later (second visit), she attended the clinic for ……… . later on (other visits
but not the last), she …………. .
Use past t.
5- Body 3: (today′s visit)
Today, the patient came reporting that ……… . Thus, ……….. .

Use past t.
6- conclusion paragraph:
Long conclusion:
My provisional diagnosis is gout. Therefore, I am referring this patient for further
management of her condition. For further queries, please do not hesitate to
contact me. (27 words)
Yours sincerely,
Doctor
Short conclusion:
In view of the above, I am referring this patient for further management of her
condition. For further queries, contact me. (21 words)
Yours sincerely,
Doctor
Some used expressions and sentences:
 Mrs .. Is a widowed woman with 4 children, but she lives alone.

 Mrs … is a single woman whose medical history is unremarkable except for
allergy to certain drugs as …..
 Mr …. Is a single man who is known to be smoker.
 Ms … is a single non-smoker patient who has history of ….
 Ms …. Is a single woman who used to live with her boyfriend with no family
in Australia. (November 2014)
 She does not smoke nor drink.
 However he does not smoke, he is a heavy drinker.
 He is a heavy smoker and he drinks as well.
 She has osteoarthritis along with aortic valve replacement. (March 2015)
 The patient was referred upon his request. (May 2014)
 As a result, he was commenced on …..
 Adherence to Pulmicort is reinforced. (October 2014)
 Eventually, she agreed on the referral to a psychiatrist. (November 2014)
 Please informing about the possibility of surgery is highly appreciated. (July
2014)
 She has osteoporosis and dementia, for which has been prescribed …..
 She was non compliant to her treatment.
 Your advice on the duties that can be done is highly appreciated. (June 2015)
 But unfortunately his condition achieved no improvement.
 Fortunately, the asthma was controlled by ….
 The patient regrettably presented with worsening symptoms.
 His medical history is unremarkable apart from being overweight.
 It is worth mentioning that ….
 The patient presented complaining of ….
 The patient came reporting that …..
 The patient attended the clinic for …..
 Remember to use the joining words as:
; therefore, ; however, ; hence , ; consequently ,

; in addition, ; then, ; thus , ; moreover ,
Discharge letter:
 In introduction :
I am writing this letter to update you with the status of Ms …
provide details about the condition of Mr ….
to inform you about …..
to discharge Mr … into your care.
 In body 1 :
The GP already knows the patient, so no need to mention social and past
medical history, so give less details in this body, or it is better to omit.
Example discharge letter: (May 2015)
Dr Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater
23/05/2015
Dear Dr Bradbury,
Re: Ms Isabel Garcia D.O.B. 01/01/1995
I am writing this letter to update you with the status of Ms Garcia, a 20-year-old
university student, who is presenting with symptoms and signs suggestive of
meningitis. I would be glad if you could further follow up her close contacts and
manage their condition as you think appropriate.
Ms Garcia is a single woman whose medical history is unremarkable except for

allergy to certain washing detergents. Please note, her mother died of breast
cancer. We can omit this paragraph
Today, the patient presented complaining of neck stiffness, photophobia and rash.
Consequently, blood tests and lumbar puncture were done which unfortunately
revealed that the patient had bacterial meningitis. Thus, she initially commenced
ceftriaxone and dexamethasone; in addition, she was prescribed benzylpenicilline
after the blood culture appeared.
The patient′s close contacts as family members and friends should seek medical
attention for the possibility of having any sign of meningitis as well as giving the
recent close contacts chemoprophylaxis. It is worth mentioning that the
Department of Human Services was also notified.
In view of the above, I am referring this patient who has just been treated for
further follow up of her and her close contacts. For further queries, please do not
hesitate to contact me.
Yours sincerely,
Doctor

Writing Notes: The Ideal Letter Should Have 6 Parts

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What are the components of an ideal referral letter?

What are the different parts of the body section in a referral letter?

Writing notes

 Time is 45 minutes : 5 minutes reading and 40 minutes writing.

The ideal letter should have 6 parts :

Other sentences that can be used in this paragraph:

3- Body 1: (social and medical history )

On 02/12/2016(first visit), the patient initially presented complaining of ……… ;

5- Body 3: (today′s visit)

Today, the patient came reporting that ……… . Thus, ……….. .

 Mrs .. Is a widowed woman with 4 children, but she lives alone.

; therefore, ; however, ; hence , ; consequently ,

Example discharge letter: (May 2015)

Ms Garcia is a single woman whose medical history is unremarkable except for

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