How to improve writing a good medical referral letter?
Good planning is the key to success. In order to plan strategically, a thorough understanding of the case notes is essential to ensure a correct response to the task question. The recipient to whom the letter is to be addressed must be crystal clear at the commencement of the letter itself. Once it is already confirmed on who would be the addressee of the medical referral letter, the purpose of writing the letter must be explained in a straight forward manner. The selection and elucidation of the case notes must be based on the information that is crucial for the reader based on which necessary action can be executed instantly without any further delay. Too many case notes are given by the examiners to distract the test takers. Unwanted particulars in the case notes are not important for readers. The particulars to be summarized and paraphrased must be also known while drafting a medical referral letter. Writing to the point can only help referral letter writers to shorten the body paragraphs and yet fulfill the word requirement as expected between 180 and 200. Incorporating unnecessary case notes can make the letter absolutely unfocussed and invariably long which may not do justice to the write up work.
An ideal example is the case notes of Ashley Kim wherein she was subject to physical abuse by her husband Brad Park and the fact is that she visited the health care centre first, six months before, and thereafter every alternate month also until the Police Case Report came to limelight a day before the drafting of her case history. Having experienced the worst scenario from her life partner, she and her son Alex Park requires shelter at Women’s Shelter and the authority to grant permission is the Director of Women’s Shelter as per the medical referral letter addressed by the health care professional of Brisbane Sprit Hospital Burn Ward to her.
The challenge while corresponding to the Director of Women’s Shelter is to present the details that can enable the Director of Women’s Shelter to take action which means grant shelter willingly to Ashley Kim and her son Alex Park.
Since the Director of Women’s Shelter is going to provide shelter, he/she needs to know the social background of the patient followed by the history of health, current abuse and involvement of other health professionals. However, the details pertaining to past admission and treatment need not be specified at all because the Director of Women’s Health will not act on that information. Special focus must be given to any patient’s current health condition which is supposed to be the recovery stage from burn injuries. The detailed case notes of Ashley Kim is followed by the writing task also.
CASE NOTES – ASHLEY KIM
Today’s Date:- 21/02/2018
Patient’s Details
Name:- Ashley Kim
DOB:- 14/02/1993
SOCIAL HISTORY:-
Patient lives with boyfriend, Brad Park and their biological son in a one bedroom rental flat.
Employment Status:- Ashley part-time waitress in a Koran restaurant
Brad:- unemployed 18 months, binge drinker
Patient’s parents live in Seoul South Korea
Son:- Alex Park, 5 years old, single child, attends the child care centre when Ashley works
MEDICAL HISTORY:-
Good past health
No known allergies 10/08/2017 attended emergency department AED with bruises over left face, right eye and forehead.
Examined by triage nurse @ triage station? Domestic abuse
Vital signs V/S Stable
Emotional:- weeping, avoidance
Patient claimed fell off the stairs, denied being assaulted by others
Assessed by the Medical Officer MO
x-ray XR Skull: no FRACTURE # seen
No active bleeding
Prescribed Hirudoid cream, referred to Clinical Psychologist (CP) for follow up
Patient refuses the referral and discharge home
17/10/2017
Attend Emergency Department AED with son. Personal Examination PE by Medical Officer MO with large bruises over Right Upper Quadrant (RUQ) at abdomen, corner of mouth and right elbow.
USG: ABD: No internal bleeding, however checked x-ray CXR # LT 6TH RIB
Son:- crying and scared accompanied by hospital volunteers?
Domestic abuse. Suggest admission to r/o insidious bleeding of internal organ
Patient refused and denied abuses by others
Patient insisted of discharging
25/12/2017
Attended AED with son. P/E by MO with some burn marks over four limbs
Caused by cigarettes, bruises over right face, bilateral eyes and forehead
XR Skull: no # CTB mild contusion over right frontal area, no bleeding
Suggest admission for further monitoring and referred to CP and MSW
Patient refused. Discharged home.
20/02/2018 Police Case Report
Son was locked up in the bedroom when violence occurred
Brad forced Ashley on to ground, poured pot of hot water on her. Ashley screamed and yelled for help.
Brad pointed a knife to Ashley.
Threatened to kill her if she called the police.
Son cried loudly. Neighbor was alarmed and called the police for her
Ambulance arrived and Ashley transferred to AED. Brad arrested by police.
Ashley assessed by MO
10% burn over bilateral lower limb
BP fluid resuscitation, no obvious injuries, RR? Pain
Admit to burn ward for further management
T/I to Burn Ward
Continue fluid resuscitation
4 morphine @ 1mg/hr. for pain
Commence prophylactic antibiotic: Flucloxacillin 1g 4 stat
Take Wound swab x C/ST
Arrange for OT X Surgical debridement
Cleanse wound by wound nurse a/c Burn Wound Management Protocol before OT suite available
Son cared by the Hospital Child Welfare Centre
Refer to CP to identify? PTSD X Ashley and son; counselling and emotional support for domestic violence causalities
Ashley’s GC: Not fit X statement, statement pending until MO’s decision
Writing Task
You are a health professional working at the Brisbane Spirit Hospital Burn Ward. Using the information provided, write a referral letter to the director of the Women’s Shelter, Harmony West, 12 west, and St. Northbridge, QLD 4543.
Explain the reason for the referral, condition of the patient and the subsequent arrangement for Ashley and her son.
In your answer:-
Expand the relevant case notes into complete sentences
Do not use note form
Use correct letter format
The body of the letter should be approximately 180-200 words
As per the details given in the case notes the date today is 21/02/2018 and the first visit was on 10/08/2018 which means 6 months ago. The second visit was two months later dated 17/10/2017. The third visit to the health care centre was in another subsequent two months dated 25/12/2017. The current admission of the diseased is on 20.02.2018.
INTRODUCTION OF THE LETTER.
Dear Sir/Madam,
Re:- Ashley Kim DOB:- 10.02.1992
I am writing this letter to refer a 25 year old diseased Korean woman Ashley Kim who has been a victim of physical abuse but is fortunately on the verge of recovery from injuries.
Paragraph 1 reveals the social history of the patient Ashley Kim which would give a big picture of her to the Director of Women’s Health.
Social History
Patient lives with boyfriend, Brad Park and their biological son in a one bedroom rental flat. Ashley, part-time waitress in a Korean restaurant; Brad unemployed 18 months, binge drinker. Patient’s parents live in Seoul, South Korea. Son:- Alex Park, 5 years old, single child, attends the child care centre when Ashley works
Paragraph 1
Ashley was residing with her boyfriend Brad Park and her five year old son, Alex Park. She was working as a part-time waitress but unfortunately Brad had been both unemployed for 18 months and had a history of being a binge drinker. Ashley’s son Alex was associating himself with a child care institute when Ashley was working.
The social history of Ashley Kim as depicted in the case notes is written as ‘patient lives’ but while transferring the case notes to a letter format, it is written as Ashley ‘was living’ The reason being that, Ashley was physically abused by Brad so it is most unlikely that Ashley would go back to live with him. She most probably may not return to her part time job either so there also the tense is she ‘was working’ although it is also presented as ‘works as’ in the case notes. Even her son Alex ‘was studying’ at a childcare centre as against he/she ‘attends’ a child care centre because the present situation is never the same after Ashely was subject to physical abuse.
MEDICAL HISTORY:-
Good past health
No known allergies 10/08/2017 attended emergency department AED with bruises over left face, right eye and forehead.
Examined by triage nurse @ triage station? Domestic abuse
Vital signs V/S Stable
Emotional:- weeping, avoidance
Patient claimed fell off the stairs, denied being assaulted by others
Assessed by the Medical Officer MO
x-ray XR Skull: no FRACTURE # seen
No active bleeding
Prescribed Hirudoid cream, referred to Clinical Psychologist (CP) for follow up
Patient refuses the referral and discharge home
17/10/2017
Attend Emergency Department AED with son. Personal Examination PE by Medical Officer MO with large bruises over Right Upper Quadrant (RUQ) at abdomen, corner of mouth and right elbow.
USG: ABD: No internal bleeding, however checked x-ray CXR # LT 6TH RIB
Son:- crying and scared accompanied by hospital volunteers?
Domestic abuse. Suggest admission to r/o insidious bleeding of internal organ
Patient refused and denied abuses by others
Patient insisted of discharging
25/12/2017
Attended AED with son. P/E by MO with some burn marks over four limbs
Caused by cigarettes, bruises over right face, bilateral eyes and forehead
XR Skull: no # CTB mild contusion over right frontal area, no bleeding
Suggest admission for further monitoring and referred to CP and MSW
Patient refused. Discharged home.
20/02/2018 Police Case Report
Son was locked up in the bedroom when violence occurred
Brad forced Ashley on to ground, poured pot of hot water on her. Ashley screamed and yelled for help.
Brad pointed a knife to Ashley.
Threatened to kill her if she called the police.
Son cried loudly. Neighbor was alarmed and called the police for her
Ambulance arrived and Ashley transferred to AED. Brad arrested by police.
Ashley assessed by MO
10% burn over bilateral lower limb
BP fluid resuscitation, no obvious injuries, RR? Pain
Admit to burn ward for further management
T/I to Burn Ward
Continue fluid resuscitation
4 morphine @ 1mg/hr. for pain
Commence prophylactic antibiotic: Flucloxacillin 1g 4 stat
Take Wound swab x C/ST
Arrange for OT X Surgical debridement
Cleanse wound by wound nurse a/c Burn Wound Management Protocol before OT suite available
Son cared by the Hospital Child Welfare Centre
Refer to CP to identify? PTSD X Ashley and son; counselling and emotional support for domestic violence causalities
Ashley’s GC: Not fit X statement, statement pending until MO’s decision
The patient Ashley’s medical history need to be mentioned and this happened so on three different dates such as 10/08/2017, 17/10/2017 and 25/12/2017. These three earlier hospitalizations of Ashley needs to be summarized. All the details on three different dates must be presented in a condensed form. Whatever is highlighted in the medical history only need be presented in consolidated manner in a paragraph.
Paragraph 2
Since August 2017, Ashely who has been subject to hospitalization was admitted at the Emergency sector on three instances with a wide range of injuries, bruising, fractures and burns also. Exemplary diagnosis and treatment has been meted out to her each time. However Ashley has refused psychological support and also denied the possibility of a physical abuse.
The patient’s final visit on 20/02/2018 also need to be presented in a precise manner in yet another paragraph.
Paragraph 3
On 20/02/2018, a grave incident of domestic abuse was exposed as per the police case report wherein Ashely Kim was a victim of physical torture due to which she was subject to crucial burns on her lower limbs and her life itself was in jeopardy. A neighbor informed the police and Brad was taken to custody. She was transported by the ambulance to the emergency department and is currently being given medication and treatment for her burn injuries.
The case notes explains the physical abuse meted out to Ashley Kim by Brad at length but the same is summarized. Moreover, the passive sentences are used to present the letter in a very formal and professional manner. The neighbor communicating the violence against Ashley was also just briefed without explaining her emotional state. Even the medication given to her that was specified in detail as per case notes is written in a condensed form.
Paragraph 4 – Discharge Plan
Ashley’s son is nurtured at the health-care center’s Child Welfare Center. It is important to note that, they have also been brought to a clinical psychologist for practicable post-traumatic stress disorder followed by counselling and emotional support.
I would value it if you could provide shelter for Ashley and her son after discharge.
Yours sincerely,
(s
Present Perfect tense can be used when writing the discharge plan as the last paragraph of the letter. It shows that the action is completed with an outcome in the present situation. Expand the abbreviations given in the case notes. A polite closing line enables the reader to take action immediately. Usage of model verbs would and could transforms the sentence in a rather respectable manner. A lot of medical details had been specified in the case notes on what was done in the ward and if the letter were directed to a health-care professional, all the detailed presentation on diagnosis and treatment in the case notes would have been relevant, but in this case, since the letter is directed to the Director of Women’s Shelter, the relevance to detailed diagnosis and treatment is ruled out as Ashley Kim and her son Alex Park only need to be provided shelter at Women’s Shelter.
The final state of the medical referral letter is like this:-
To,
Director of the Women’s Shelter, Harmony West,
12 west,
St. Northbridge, QLD 4543.
Dear Sir/Madam,
Re:- Ashley Kim DOB:- 10.02.1992
I am writing this letter to refer a 25 year old diseased Korean woman Ashley Kim who has been a victim of physical abuse but is fortunately on the verge of recovery from injuries.
Paragraph 1
Ashley was residing with her boyfriend Brad Park and her five year old son, Alex Park. She was working as a part-time waitress but unfortunately Brad had been both unemployed for 18 months and had a history of being a binge drinker. Ashley’s son Alex was associating himself with a child care institute when Ashley was working.
Paragraph 2
Since August 2017, Ashely who has been subject to hospitalization was admitted at the emergency sector on three instances with a wide range of injuries, bruising, fractures and burns also. Exemplary diagnosis and treatment has been meted out to her each time. However, Ashley has refused psychological support and also denied the possibility of a physical abuse.
Paragraph 3
On 20/02/2018, a grave incident of domestic abuse was exposed as per the police case report wherein Ashely Kim was a victim of physical torture due to which she was subject to crucial burns on her lower limbs and her life itself was in jeopardy. A neighbor informed the police and Brad was taken to custody. She was transported by the ambulance to the emergency department and is currently being given medication and treatment for her burn injuries.
Paragraph 4 – Discharge Plan
Ashley’s son is nurtured at the health-care center’s Child Welfare Center. It is important to note that, they have also been brought to a clinical psychologist for practicable post-traumatic stress disorder followed by counselling and emotional support.
I would value it if you could provide shelter for Ashley and her son after discharge.
Yours Sincerely,
Health Care Professional
