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Guidelines for good writing

Guidelines for good writing

How to write a good referral

The referral letter should contain both adequate and accurate administrative and clinical information.

 This includes:

  • 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

  • Recently

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

 Punctuation Rules 

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.

Comma

  1. a) Is used to separate list of items (,) .Ex- I like reading, traveling, listening to music and cooking.
  1. b) To separate phrases –

Examples:

  • He should recover first, in order to get discharged.
  • The doctor should perform some tests, before coming to a conclusion on malaria or typhoid.
  1. c) To introduce direct quote-

Example:

  • The doctor said, “If you don’t quit smoking, you run the risk of a heart attack”.
  1. e) To separate noun phrases-

Example:

  • Chris, who is a two time Olympic swimming champion, is deaf and dumb from birth.

Semicolon

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.

Examples:

  • 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.

Colon

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.

Examples:

  • 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

Rule -1

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.

Rule- 2

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

Rule -3

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.

 Rule- 4 

Capitalize the person’s title when it follows the name on the address or signature line.

  • Sincerely,

             Dr. Smith

Chairperson

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

Rule- 6

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

 

June 1, 2016

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