lOMoARcPSD|28646932

Ultimate Writing Template

OET medicine writing template (Shahid Beheshti University of Medical Sciences)

Scan to open on Studocu

Studocu is not sponsored or endorsed by any college or university

Downloaded by Paul Violeta (pifoy007@gmail.com)
 lOMoARcPSD|28646932

Types of letters & their layout:

Referral Transfer Discharge

Introduction:
Purpose of letter Must add: When, where & why was
Brief history of patient When & where would the patient admitted
(name, age, occupation) the patient be When is the patient
Brief history of current transferred being discharged
situation Chief complaint Recovery status
Brief outline of action Recovery status
needed
Main body: items labelled according to the number of paragraphs
Note: the structure of the main body should fit the case notes provided in the
exam.
 Present history +/-  Complaint & initial  Chief complaint,
social/family history if management initial management
included (medication,  Secondary complaint +/- social history
allergy, special habits) or current condition (unless letter to GP)
 Past history: history  Details regarding the  Secondary complaint
of relevant previous transfer & or current condition
visits management plan, as  Details regarding the
If letter to GP, don’t well as detailing any discharge &
include extensive past specific requirements management plan, as
history as the GP most regarding patient well as detailing any
likely knows the patient. management specific requirements
 Current situation, regarding patient
management & management
response of patient to
treatment/recovery
Conclusion:
Overview of the current situation
Request regarding management plan
Offering further help if required

Downloaded by Paul Violeta (pifoy007@gmail.com)

 lOMoARcPSD|28646932

Introduction
(Usually 2 sentences, 25 words, present tense)

First sentence:
Referral letter:
 I’m writing to you regarding/with regard to … or to refer … into your care/for additional
care/assessment
 (As arranged with your receptionist) thank you for seeing … (whose referred for further
assessment of … or who’s currently suffering from …)
Discharge letter:
 I’m writing to update/inform you on the status of/regarding … who is being discharged
today/ready for discharge today after …
 His condition is improving/he’s recovering well/he’s making a full recovery and is being
discharged today into your care.
 He’s closely monitored for …, all of which are absent.
Urgent:
 I’m writing this letter to request an urgent/prompt/immediate review of …
 Thank you for urgent attention to …
Mention patient name, age & occupation, ex: Mr. Smith, a 60 year old farmer (who has been a
patient of mine for a long time. Currently, he)
 Who was admitted to … on ... (for checkup/routine assessment/diagnosis or with the
diagnosis of)
 Presenting with/suffering from/demonstrating features/signs & symptoms
suggestive/indicative/consistent with …
 Who is recovering from … (an operation/treatment)/having an acute exacerbation
of …/requires/was diagnosed with … on …

Second sentence:
 Therefore, your urgent assessment/intervention/further management would be highly
appreciated/ his condition needs your management.
 Your advice on how to cope with his new diagnosis/deal with this new situation would
be valuable.
 I would be grateful/appreciate it/be glad if you could further manage/follow up … as
you think appropriate.

Downloaded by Paul Violeta (pifoy007@gmail.com)

 lOMoARcPSD|28646932

Main body:
2 or 3 parts, 45 words each, variable tenses

Present history: describing different visits:

First visit: initially/during regular checkup, the patient …
Today’s visit: on today’s visit/review/consultation,
 The patient (accompanied by) presented with/attended the clinic to review the test
results, which were …
 The patient visited the clinic, complaining of … which has been present for/accompanied
by/triggered or provoked by/related to
 The patient’s condition set in with …/has become problematic
 The patient also stated/complained/experienced/reported/described/exhibited signs of.
However, the patient denied having …
 The patient seemed/appeared/looked
On examination, the patient/BP was found to be …/showed signs of. The examination was
unremarkable/uneventful/there were no abnormal findings, except for/apart from … or … was
noted/observed
Therefore, investigations (lab tests/imaging/intervention and other relevant investigations)
were ordered/run/requested/conducted/performed
 Which showed/demonstrated/revealed/indicated/confirmed/identified/excluded/ruled
out
 Which were suggestive of
Medication was prescribed/commenced/instituted or adjusted/modified/altered or
discontinued/terminated. The patient was managed with or the patient is currently on …
The prior advice was modified to …/a review was scheduled
The patient:
 Was advised/encouraged to/reassured
 Instructed that if he gets worse within/develops …, he should …
 Informed that he’s due to get … (something done).
 Counselled on the potential diagnosis together with the need for further investigations
 Some strategies regarding … were discussed/recommended/suggested and information
brochures were provided/appointment with support group was arranged/ visit to …
organized

Downloaded by Paul Violeta (pifoy007@gmail.com)

 lOMoARcPSD|28646932

 Was given sick leave certificate

Patient’s response:
 The recovery was uneventful/uncomplicated/successful. The patient made a routine
recovery/made good progress (and the … is currently scheduled).
 The condition
 Resolved/improved/subsided/recovered/well-controlled, the … ceased,
the patient has become stable
 Worsened/deteriorated/exacerbated, limiting/restricting/impairing
patient’s ability to …/
 Despite the treatment/advice/adherence to medication, there were no signs of
improvement/minimal relief/poor response to the medication/the symptoms
persisted, weren’t relieved or settled/the same previous signs were detected
Adverbs: considerably/significantly/markedly/extremely, gradually/steadily.

Other visits:
Following this visit/on subsequent visits,
 If uneventful: the patient came on different occasions for other medical issues
 If important: the patient later presented with a new complaint of/reported … especially
after …/attended the clinic with 2 day history of …

Personal history: (if important points: kindly note)

 Special habits (smoker, occasional/frequent drinker)
 Diabetes/hypertension/hyperlipidemia/allergy
In terms of/regarding medical history,
 There’s no history of/there are no known allergies/his past history is unremarkable
 The patient has been suffering from recurrent attacks/episodes of … which are managed
accordingly/has been hospitalized on several occasions with severe
 The patient has … for which he has been taking … regularly.
 He has been a patient in my clinic for …, during which he presented on several occasions
with …
 His past history includes/his medical records show
 Risk factors for … include …

Downloaded by Paul Violeta (pifoy007@gmail.com)

 lOMoARcPSD|28646932

If newborn: he was delivered vaginally/by caeserian section at … weeks gestation with no

complications.

Family history:
 He has no family history of …
 Apart from positive family history of … in his father, he has otherwise been well or his
father has died of … at the age of … or his family history is notable for …
Social history: marriage status, children, siblings, parents (if living alone, highlights need for
maximum attention)

Making requests related to the management plan:

Using emphasis: please/kindly note that, it’s important to know, it’s worth mentioning that

 Could you please/would you kindly/please ensure that/the patient would require
(organize a visit, arrange an appointment, great care is needed)

Conclusion: 25 words
First sentence:
 In review of the above/signs & symptoms, in light of/based on/considering/taking into
account
 My provisional diagnosis/I believe the symptoms & signs are consistent with
 I believe that the patient needs …,thus the patient is referred to your care/for full
assessment
 I’m referring this patient, who has just been treated for … for further management or
assessment/continuous follow up, also including possible intervention or to see if he
requires any further management/intervention.

Second sentence:
 Therefore, I would be grateful/appreciative/thankful if you could follow up/manage her
condition as you think appropriate or if you could discuss/advise the patient regarding.
 I would request you please look into/take over the case and …

Downloaded by Paul Violeta (pifoy007@gmail.com)

 lOMoARcPSD|28646932

 Your expert views/opinion on what the definite diagnosis & how the condition be
managed accordingly would be highly appreciated or I would be grateful for your
thoughts on the possibility of.
 I would appreciate your urgent attention for his condition.
 I would appreciate it if you could keep me informed about his progress/further
management.
 Thank you for looking after/for the continuous follow up of this patient.
For any queries/should be any queries/for further assistance/if you require further
information, please don’t hesitate to contact me.
All the reports are being attached to this letter.

Yours sincerely
Useful vocabulary
Cause & As a result/consequence
effect Therefore/thus/hence
Owing to
Given
Subject With regard to, based on, in terms of, in view/light of
Addition In addition, additionally
Moreover, furthermore
Apart from that
Emphasis & For your information, it should be noted that
clarification My main concern, what concerns me the most is
To illustrate/clarify/explain, specifically, particularly, in this respect
Contrast Nevertheless, nonetheless
However, on the contrary, on the other hand
Sympathy (un) fortunately, regrettably
Time On (date), today’s review, over the …, following, since that time
Upon the first visit
At that stage/time
On occasion, at times
Place During hospitalization, on examination
Sensitive BMI of … NOT overweight
language Self-harm NOT suicide
Discomfort vs pain
The patient managed to lose weight/cut their smoking

Downloaded by Paul Violeta (pifoy007@gmail.com)