Refer ‘Treatment Record’ and ‘Current Medication’. Tip 16: The patient’s medical history can be written here in this letter as related reference is made in the following parts of the letter. Treatment record: Sep 2017 Diagnosed with type 2 diabetes August 2016. Fasting blood sugar levels (BSL) = 9Doctor recommended dietary management: low-fat, low-sugar, calorie restriction; limit alcohol. ↑Exercise Pt lives at home with wife. Wife cooks. Wife managing dietary requirements, but Pt likes 2-3 glasses wine with meals Dec 2017 Wife deceased. Pt depressed/grieving. Referred back to doctor for monitoring/medicatingFasting BSL = 9. Pt non-compliant with diet. Excessive fat, salt, sugar, alcohol (wine/beer) Mar 2018 Doctor prescribed metformin (oral hypoglycaemic agent). Now Pt cooking for self –non-compliant with diet. Non-compliant with medication. Blames poor memory Pt appears unmotivated. Resents having to take medication: ‘always been healthy’ Takes medication intermittently; encouraged to take regularly Educated regarding need for regular medication and potential adverse effects of intermittent dosing Discussed strategies of memory aids Jun 2018 Pt hospitalised (City Hospital, Newtown) with myocardial infarction (MI) following retrosternal pain, nausea/vomiting, dizziness, sweating. Confirmed by ECGTreatment: aspirin, streptokinase infusion. Prescribed ramipril 5mg daily. Diagnosed with atrial fibrillation post MI – commenced sotalol and warfarin Jun-Aug 2018 Pt attended twice weekly Tip 17: Identify relevant information/details. Keep in mind the reader has to take over the care once the patient relocates. - Medical history with year of diagnosis
- Regular medications and their doses
- Unhealthy diet
- History of non-compliance
Tip 18: Group information logically so that the reader does not have to re-read the letter to understand it. Tip 19: Avoid Repetition of information. For example, ‘History of non-compliance’ is relevant but is discussed repeatedly on 3 separate visits. Instead of discussing that repeatedly in the letter, mention that information in this paragraph. Using ‘Please note,’ emphasises that point. Tip 20: Avoid Irrelevant information: Information not related to the chief complaint of the patient and not useful to the reader, an emergency department consultant, 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. For example, life with late wife, (obvious) advice given, symptoms of MI and treatment given in the hospital Tip 21: Sequence relevant information based on importance. Tip 22: Use last name (surname) with appropriate title when referring to the (adult – aged above 16) patient initially in a body paragraph. Avoid using pronouns to refer to the patient at the first occurrence in a paragraph. Tip 23: Use punctuations appropriately when listing medications and their doses in a sentence. Tip 24: Avoid capitalizing generic drug name(s). (If you are using brand names, capitalize accordingly.) Let’s compile relevant information and compose the body paragraph 1 as follows. Mr Dunbar has had type 2 diabetes since 2016 and had been compliant with the management until the death of his wife in December 2017. In June 2018, he was hospitalised with myocardial infarction and subsequently diagnosed with atrial fibrillation. His current medications are metformin, 500mg three times a day; ramipril, 5mg daily; sotalol, 40mg daily and warfarin, variable 3-5mg. Please note, he consumes excessive fat, salt, sugar and alcohol against the recommended diet and has a history of poor medication compliance, which he attributes to poor memory; he also double-doses occasionally. |