Guidelines for good writing
How to write a good referral
The referral letter should contain both adequate and accurate administrative and clinical information.
- The name, address including post code, date of birth, and gender. A contact telephone number is helpful.
- The summary of the patient’s relevant medical and dental history.
- A clear indication of the condition initiating the referral and any patient preferences. If treatment is not required and the referring dentist is requesting advice only (or a second opinion) this must be clearly stated in the letter.
- An indication as to the level of urgency of the condition.
- .Mention any relevant test results and radiographs that are attached to the referral letter.
Use of tenses
Pay attention to the use of tenses in your sentence structure:
- Use present tense to talk about the patient’s current condition or to make an observation:
- The patient is suffering from__________ /has severe pain in her left leg/has swelling in her joints
- Please note that Mr. Roth is a chain smoker/is HIV+/is hypertensive
- Levine has a history of allergies
- Use past tense to talk about the patient’s condition in the past or to talk about what procedure he/she followed:
- The patient fell from her horse and suffered a fracture/had an operation to remove her tumor
- Roth took Panadol for pain relief/brought his x-ray to show me
- He was treated with…
- Use present perfect tense to talk about the recent past”
- The patient has been suffering from___________ since the past two days
- The patient has taken __________ for pain relief
- I have examined _____________ and observed that…
- Use the past perfect tense to talk about the patient’s history before he/she came to see you or something that happened a few years ago
- The patient has had two surgeries in the past to remove a lesion in her brain
- Levine has had two of her molars removed
- Roth has never had any treatment done for his…
- The patient has had crutches for the past two years
Talking about time:
- Several months ago/two months ago
He had a surgery to_____________ two months ago/Several months ago he had come to me complaining of______________
- Since a long time/since two days
He has not had a follow-up since a long time/he has had pain since two days
- For a long time
He has been suffering for a long time without taking any medication
The patient has recently had her teeth cleaned
- In the last two years/two months
Her condition has deteriorated rapidly over the last two months/years
Full stop –
– Put full stop (.)at the end of the sentence. Ex- Mr. Murray has undergone the stress test and as expected failed the test.
- a) Is used to separate list of items (,) .Ex- I like reading, traveling, listening to music and cooking.
- b) To separate phrases –
- He should recover first, in order to get discharged.
- The doctor should perform some tests, before coming to a conclusion on malaria or typhoid.
- c) To introduce direct quote-
- The doctor said, “If you don’t quit smoking, you run the risk of a heart attack”.
- e) To separate noun phrases-
- Chris, who is a two time Olympic swimming champion, is deaf and dumb from birth.
You will usually use the semicolon (;) to link independent clauses not joined by a co-ordinating conjunction. Semicolons should join only those independent clauses that are closely related in meaning.
- Abdominal exercises help prevent back pain; proper posture is also important.
- He has been having a headache since the past two days; his toothache is better
- Michelle was in pain: she had sprained her ankle.
The colon (:) is used to introduce series, lists, quotations. The first part of the sentence should introduce the second part. The second part should give additional details.
- He had many reasons for joining the health center: to get in shape, to make new friends, to lose some weight, and to get out of the house.
- The nurse gave the patient the sedatives for the following reasons: unbearable pain, inability to sleep , treatment of wounds
- Re:Rehabilitation of Mrs.Rosalind Turner
Use of capital letters
Capitalize the first letter at the beginning of a sentence and after a full stop.
- His knee was bleeding. An ointment was applied. No bandage or sutures required.
Capitalize a proper noun. For people’s names the first name and the last name has to begin with a capital letter
- Golden Temple, Amritsar, Australia, Jack Robbins, Mary Firth
Capitalize the first letter of the person’s title if it comes before the name.
- M /Mrs., Ms., Dr. etc
- The Chairperson D Smith will address the final year medical students.
If the title “chairperson” comes in the sentence for example, there will be no capital letter used: Dr.Smith, the chairperson will address the final year medical students.
Capitalize the person’s title when it follows the name on the address or signature line.
Rule – 5
Capitalize the first word of a salutation and the first word of a complimentary close.
- Dear M Alena
- My dear M Alena
- Yours Truly/Yours Sincerely/Regards
Capitalize words taken or derived from proper nouns.
- English from England
- Spanish taken from Spain
- French taken from France
Subject names like history, maths, optometry, dentistry or pharmacy need not be capitalized in the middle of a sentence.
Summary of content of referral letters and information that specialists want in referral letters :
- Reason for referral
- History of problem
- Medical history
- Clinical findings
- Findings on investigation/tests
- Current medication
- Socio psychological matters
- Known allergies
- What referring doctor expects from referral
- Whether new referral or re-referral
- Previous therapy/interventions
- Provisional diagnosis
- Request for copy of consultation report
- Statement about expectation for return of patient