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]

  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 letter should have accurate spelling, use correct grammar and syntax, and be succinct.

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.[2]

The following is what should be included as part of a quality clinic letter.

New Patient

  • Identifying data: date of consultation, place of consultation, and supervisor name if a trainee.
  • Patient data: name, address, date of birth, contact details, and ethnicity
  • Insurance details: ACC details if appropriate or other
  • History: History of the index condition and associated symptoms. Including mechanisms of injury, initial symptoms, chronology. Include previous assessments with other doctors and previous interventions.
  • PMHx/PSHx: Other current and past medical, musculoskeletal, and orthopaedic history
  • Medications and adverse drug reactions.
  • Psychological and social history: Including marital status, occupation and nature of work, sports, hobbies, interests, smoking, alcohol, and drug use.
  • Physical examination findings. Include comment about pain behaviours, VAS/NRS, disability or psychological assessment measures, pertinent positive and negative physical signs.
  • Previous Investigations
  • Formulation. Use correct terminology (IASP classification) where possible and provide clinical reasoning for the diagnosis.
  • Management plan. Discuss plan and contingencies, any treatments done at the visit, what to do in the event of a complications, and what the follow up plan is.
  • Summary. Succinct summary of the problem and management.

Follow Up

  • Identifying data: date of consultation, place of consultation, and supervisor name if a trainee.
  • Patient data: name, address, date of birth, contact details, and ethnicity
  • Insurance details: ACC details if appropriate or other
  • Progress: summary of clinical progress, investigations to date, response to treatments, and any new developments
  • Examination: focused and appropriate. Record any VAS/NRS or assessment measures
  • Formulation. Review of the formulation with clinical reasoning
  • Management. Discuss plan and contingencies, any treatments done at the visit, what to do in the event of a complications, and what the follow up plan is.

See Also

References

  1. Ten top tips for writing an outpatient letter | The Royal College of Radiologists (rcr.ac.uk)
  2. Rayner, Hugh; Hickey, Martha; Logan, Ian; Mathers, Nigel; Rees, Peter; Shah, Robina (2020-01-27). "Writing outpatient letters to patients". BMJ (in English): m24. doi:10.1136/bmj.m24. ISSN 1756-1833.