Presentation on theme: "How to write a surgical correspondence?"— Presentation transcript:
1How to write a surgical correspondence? Paul LaiSurgery, CUHK
2Workshop covers Surgical consultation Reply letter to referring doctorsRequest for imagingMedical reports
3Surgical Consultation Purpose ?Where to seek help ?Forms of consultation ?WrittenVerbalWritten consultation formWho is this consultation addressed to?Patient’s particularCurrent state of affairs / diseasesClinical problem(s)What kind of help do you want?Can the patient wait (urgent vs. elective)?
4Surgical Consultation (con’t) Verbal consultationBe courteousBe clearAsk for confirmation as a kind of “talk back” (especially in important cases or urgency)Documentation on the case notesOn writing case notesBe clear, legible writing is a mustDate, time, chopDo not use the case note as your “war zone”Do not put down anything that would hurt the feelings of your colleaguesDo not put down anything to diffuse your responsiblity
5Reply letter to referring doctors A good practice that would earn you more patientsBe courteous (do not down-grade the referring doctors in anyway)Write clearlyWhich patient you are referring to ?(pt’s name, ID, sex, age, pt’s principle diagnosis, referring clinical problems)What is your findings of the situation?What you have done for the patient?What is your plan for the patient or suggested plan for the patient?“Thank you once again for referring your patient to me. I feel privileged in being able to help.”
6Request for imaging Patient’s particular Clinical problems Principle diagnosis or provisional diagnosisRationale for the imaging that you are requesting(need a lot of clinical sense)What kind of imaging you are requesting?Urgency of the request (urgent vs. elective)Put down your name and contact clearly (and sometimes which department you are from)
7Medical reportsYou will have the chance to write medical reports once you are medical officersOnly when you are extremely unlucky during your internship if you are to write one [you might have a medical incident to write on]FormatOne key attitude in writing medical reportsInclude only factual account of the patientNo emotions attachedNo comments are to be made in medical reports unless you are the expert witness