Referral Letter Writing Guide for OET Candidates

Full name of the recipient with title
Designation/Job title
Address

Greeting (Dear ……. ) (Second name of the recipient with appropriate title)

Reference line (Re: the patient’s full name & DOB)

Tip 1: ’20  January 2022’ is the preferred date format at the start.

Tip 2: dd/mm/yyyy is the preferred date format in in the reference line and paragraphs. (Avoid switching date formats in the reference line and paragraphs.)

Tip 3:  Interchanging the order of Date & Recipient’s Details is acceptable.

Tip 4:  Interchanging the order of Greeting & Reference Line is acceptable.

Tip 5:  If date of birth (DOB) is given, write that in the reference line. If age is also given, mention that in introduction.

Tip 6: If the recipient is not a doctor (Dr.), use appropriate title or job profile name (Dear Nurse, etc.)

Tip 7: Watch the spelling. If you are using British/American spelling, be consistent in the letter. Avoid mixing the styles.

18 June 2018

Dr Jason Roberts
Gastroenterologist
Newtown Hospital
11 1 High Street              
Newtown
Dear Dr Roberts

RE: Ms Anne Hall, DOB: 19/9/1972

Writing ‘introduction’ of a referral OET letter is similar to other types of letters such as a transfer or a discharge letter. It covers the full name of the patient, introduces the medical complaint and generally discusses the reason(s) for writing the letter.

Tip 8:  Keep in mind that excluding the purpose would affect your score negatively.

Tip 9:  Read the ‘Note’ & ‘Writing Task’ given at the start and end of the case notes respectively to identify the purpose.

Tip 10:  You may use the key word ‘refer’ to indicate the purpose as you are introducing the patient to another healthcare professional for the first time.

Tip 11:  Keep the introduction succinct to make the purpose immediately apparent to the reader.

TIP 12: Avoid secondary information/details that may obscure the objective of introduction.

Tip 13:  Avoid using ‘a/the/this/my patient’ to refer to the patient in the letter as it is considered less polite.

Tip 14:  Write full name with title at the first occurrence in the introduction as the patient is an adult.

Tip 15: In introduction, the purpose should be general information related to expected care/action. A specific & detailed plan should be included in conclusion.

Tip 16: Avoid using note/short forms; it is informal. For example, +/-

Introduce the patient. Refer NOTES and PATIENT DETAILS

… 45-year-old female patient

Anne Hall (Ms), DOB 19 Sep 1972

Social History: Teacher (Job can be included as it may be causing stress, but subjects taught are irrelevant)

Medical Complaint: Refer Provisional Diagnosis

Provisional diagnosis: gastro-oesophageal reflux +/- stricture

Reason for writing the letter: Refer Writing Task.

… for further investigation and definitive diagnosis

The introduction of your OET letter is now

I am writing to refer Ms Anne Hall, a 45-year-old school teacher who has features of gastro-oesophageal reflux with possible stricture, for further investigation and a definitive diagnosis.

Tip 17:  Relevant information. Select what the reader (a gastroenterologist) should keep in mind while the patient is in his care.

Presenting complaint(s)

(Possible) background of the complaint(s)

Examination Findings/Further Discussion

Addition Relevant Information Given by the Patient

Tip 18:  Use second name with appropriate title when referring to the (adult) patient initially in a paragraph.

Tip 19:  Avoid using pronouns to refer to the patient at the first occurrence in a paragraph.

Tip 20: Avoid using brackets; it is informal. Rephrase without them.

Tip 21: Avoid capitalizing generic drug name(s).

Let’s compile relevant information and compose the body paragraph 1 as follows.

Today, Ms Hall complained of constant dysphagia for solids, epigastric pain radiating posteriorly to the T12 level, and concomitant 1-2kg weight loss. According to her, the symptoms started 2 weeks ago after a viral URTI, for which she took an OTC Chinese herbal medicine with unknown ingredients. She had no apparent signs of anxiety and denied sensation of any lump. She is overweight with a BMI of 28.2. Please note, she reported occasional use of aspirin up to 2-3 times a month and a recent increase in her coffee intake.

Tip 23: Sequence relevant information based on importance.

Tip 24: Irrelevant information/details: Any information not related to the chief complaint of the patient and not useful to the reader, a gastroenterologist, to initiate the expected care/action should be ignored. Otherwise, it may confuse the reader, and even be counter-productive as it may increase the length of your letter.

Refer

Previous Medical History

Childhood asthma; chickenpox; measles
1983 tonsillectomy
1990 hepatitis A (whole family infected) 1992 sebaceous cyst removed
1995 whiplash injury
2006 depression (separation from husband); SSRI – fluoxetine 11 mths
2008 overweight – sought weight reduction
2010 URTI (Upper Respiratory Tract Infection)
2012 dyspepsia
2014 dermatitis; prescribed oral & topical corticosteroids

Social History

Divorced, 2 children at home (born 2002, 2004)
Non-smoker (since children born)
Social drinker – mainly spirits

Allergies: Codeine; dust mites; sulphur dioxide

Family History:

Mother – hypertension; asthmatic; Father – peptic ulcer
Maternal grandmother – died heart attack, aged 80
Maternal grandfather – died asthma attack
Paternal grandmother – unknown
Paternal grandfather – died ‘old age’ 94

Tip 25:  Use second name with appropriate title when referring to the (adult) patient initially in a paragraph. Avoid using pronouns to refer to the patient at the first occurrence in a paragraph.

Let’s compile relevant information and compose the body paragraph 2 as follows.

Ms. Hall is divorced and has two children. She received treatment for depression in 2006 following her divorce, sought weight reduction in 2008, had dyspepsia in 2012 and was on oral corticosteroids for dermatitis in 2014. She does not smoke but drinks socially, mainly spirits. She is allergic to codeine and has a family history of peptic ulcer. 

Tip 26:  Advice given to the patient to be considered.

Tip 27: Avoid including ‘Refer gastroenterologist for opinion and endoscopy…’ as the letter is written to the gastroenterologist.

Plan: Refer gastroenterologist for opinion and endoscopy if required

↓ coffee/alcohol intake

Cease OTC product

Pantoprazole 40mg daily

Tip 28: Avoid using note/short forms; it is informal. For example, /, ↓.

Tip 29: Shift the focus from the writer (I/we) as much as possible to maintain formal style. For example, avoid using ‘I advised …’.

Tip 30: Avoid capitalizing generic drug name(s).

This paragraph can be written as below.

Ms Hall is advised to reduce her coffee and alcohol intake, stop taking the over-the counter product immediately and take pantoprazole 40mg daily.

Refer ‘Plan’.

Plan: Refer gastroenterologist for opinion and endoscopy if required

↓ coffee/alcohol intake

Cease OTC product

Pantoprazole 40mg daily

Tip 31:  Give an introductory phrase to link the conclusion to the above-mentioned information.

Tip 32: Ensure no information related to expected care/action is excluded.

Tip 33: Note that only the information related to further care is selected from the earlier parts of case notes (see the underlined information).

Tip 34: Make sure the tone used is polite and formal.

Therefore, the letter can be concluded as below.

Given the above, Ms Hall is referred to you for an endoscopy if required and your opinion on further management.

Tip 36:  A typical polite closing sentence can be written as the addressee can get back to the writer if he needs more information about the patient.

Tip 37: It should be polite and should not include informal words and phrases.

For any further information, please contact me.

Yours sincerely (If the name of the recipient is given.)

Yours faithfully (If the name of the recipient is NOT given.)

Tip 39:  Write the name of the profession/designation indicated in the case notes. You may give the name of the hospital or organization if given (optional).

Tip 40: Leave a single blank space between all sections.

In this case, the name of the reader is given.

Yours sincerely,
Doctor

18 June 2018

Dear Dr Roberts,

Re: Ms Anne Hall, DOB: 19/09/1972

I am writing to refer Ms Anne Hall, a 45-year-old school teacher who has features of gastro-oesophageal reflux with possible stricture, for further investigation and a definitive diagnosis.

Today, Ms Hall complained of constant dysphagia for solids, epigastric pain radiating posteriorly to the T12 level, and concomitant 1-2kg weight loss. According to her, the symptoms started 2 weeks ago after a viral URTI, for which she took an over-the-counter Chinese herbal medicine with unknown ingredients. She had no apparent signs of anxiety and denied sensation of any lump. She is overweight with a BMI of 28.2. Please note, she reported occasional use of aspirin up to 2-3 times a month and a recent increase in her coffee intake.

Ms Hall is divorced and has two children. She received treatment for depression in 2006 following her divorce, sought weight reduction in 2008, had dyspepsia in 2012 and was on oral corticosteroids for dermatitis in 2014. She does not smoke but drinks socially, mainly spirits. She is allergic to codeine and has a family history of peptic ulcer.

Ms Hall is advised to reduce her coffee and alcohol intake, stop taking the over-the-counter product immediately and take pantoprazole 40mg daily.

Given the above, Ms Hall is referred to you for an endoscopy if required and your opinion on further management. For any further information, please contact me.

Yours sincerely,
Doctor