How to write a surgical correspondence?

Paul Lai

Surgery, CUHK

Workshop covers

• Surgical consultation

• Reply letter to referring doctors

• Request for imaging

• Medical reports

Surgical Consultation

• Purpose ?• Where to seek help ?• Forms of consultation ?

– Written– Verbal

• Written consultation form– Who is this consultation addressed to?– Patient’s particular– Current state of affairs / diseases– Clinical problem(s)– What kind of help do you want?– Can the patient wait (urgent vs. elective)?

Surgical Consultation (con’t)

• Verbal consultation– Be courteous– Be clear– Ask for confirmation as a kind of “talk back” (especially in important

cases or urgency)– Documentation on the case notes

• On writing case notes– Be clear, legible writing is a must– Date, time, chop– Do not use the case note as your “war zone”– Do not put down anything that would hurt the feelings of your

colleagues– Do not put down anything to diffuse your responsiblity

Reply letter to referring doctors

• A good practice that would earn you more patients• Be courteous (do not down-grade the referring doctors in

anyway)• Write clearly

– Which 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.”

Request for imaging

• Patient’s particular• Clinical problems• Principle diagnosis or provisional diagnosis• Rationale 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)

Medical reports

• You will have the chance to write medical reports once you are medical officers

• Only when you are extremely unlucky during your internship if you are to write one [you might have a medical incident to write on]

• Format• One key attitude in writing medical reports

– Include only factual account of the patient– No emotions attached– No comments are to be made in medical reports unless you are

the expert witness