Report Writing

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Report writing is the process by which the clinician summarises the salient features of the patient's condition.

Principles

The UK Royal College of Radiologists offer the following principles for outpatient letter writing:

1. Be clear on why you are writing the letter. Is it a record for treating team, information for referrer, summary for the patient. One letter can't be perfect for all people.
2. Write letters to the patient when possible
3. Use headings throughout the letter. The plan should be at the top.
4. Keep the letter brief, clear, readable, and relevant.
5. Make sure the information is up to date, accurate, and unambiguous. Diagnosis summaries should be continuously revised.
6. The treatment summary: a tool for the patient and handover of care. The treatment summary should give clear instructions on what to do and facilitates handover between secondary and primary care
7. Opinion, updated treatment plan, and next steps. When referred for an opinion it is important to put this opinion in the letter and not simply restate facts available elsewhere. Any actions should be listed with time frames and who is responsible
8. Contact details.
9. Dictation. Speak clearly, confirm patient and consultation date, find useful predefined templates
10. Feedback. Ask for feedback from colleagues.

Contents

The report generally includes

• Patient details
• Presenting symptoms
• History of the index condition
• Association symptoms
• General medical history
• Psychological and social history
• Physical examination findings
• Special investigation results
• Provisional diagnosis
• Management plan

There has been some discussion in the UK around whether reports should be written directly to patients rather than to the referrer. The article received a large number of mixed responses such as around how simple English versions of medical letters tend to make important omissions, and require considerable extra time and effort compared to the normal medical letter. However there are certain situations where a letter directed at the patient is preferable.