GP Registrar GP Training

Composing good clinic letters

Dr Mahibur Rahman

One of the problems in the NHS is the communication between primary and secondary care. As a GP you will appreciate the importance of good quality clinic letters so as a junior doctor training in hospital, start making an effort to send out good letters. This is a quick guide to what you should include:

Basics

Make sure that the following are clear from a quick glance:

•  Patient details: name, address, hospital and NHS number
•  Date and name of clinic
•  Consultant
•  Your name and contact details

Clinical details

The doctor receiving your letter wants to know 5 things from your letter, so make sure they can find all 5 quickly :

•  Diagnosis
•  Current state of disease
•  Any investigations or changes in management (include current meds / new meds)
•  Next follow up
•  What you would like the reader to do

The last is particularly important for all parties involved: you, the patient and the GP. If you have started new medications and need the GP to prescribe repeats or to monitor bloods / BP after a certain period of time, make this clear. A note on professional etiquette here: please request this rather than demand it: you are dealing with a colleague (who is likely to be more experienced/senior to you), not a child. Don’t request your colleague to do tasks that are part of your responsibility – if you have ordered investigations as part of the clinic visit, it is your responsibility to follow up the results and act on the findings.

Finally

Signing clinic letter

The secretary will probably type the letter and return it to you for signing. Read through the letter before signing to make sure there are no errors and that you have included the basics and key details.