ORGANISATION OF A DISCHARGE LETTER
Look at following flow chart-
In case of a discharge letter to new Doctor/GP/ Nurse -
1. Address
2. Introduction
3. Admission status
4. Hospitalization condition
5. Today/ discharge day’s condition and discharge plan
6. Personal/ Social/ Medical / Medication/ Family/ Allergy history
7. Conclusion
8. Closing
In case of a discharge letter to own Doctor/GP/ Nurse -
1. Address
2. Introduction
3. Admission status
4. Hospitalization condition
5. Today/ discharge day’s condition and discharge plan
6. Conclusion
7. Closing
A Sample Format
1. Doctor's/Nurse’s name
2. Speciality
3. Name of Hospital and address
1. Address 4. Today's date
5. Dear (Doctor's/Nurse last name)
6. Re: (patient's full name) D.O.B/Age(if DOB not given)
1. When the patient will be discharged.
2. Introduction 2. The patient’s final diagnosis and recovery status.
1. Complaints & Symptoms
3. Body part 1(Admission 2. Examination finding
status) 3. Diagnosis & Treatment:
Drug/advice/investigation
1. Patient condition- Improvement or
4. Body part 2 deterioration or new symptoms
(Hospitalization development.
condition) 2. Any specific/special recommendation.
1. Final Condition
4. Body part 3 2. Discharge plan
( Today’s condition and 3. Medication and special attention.
discharge plan)
1. Personal history(marital status/smoker/alcholic/profession)
5. Body part 4 2. Medical history
3. Medication history
4. Family history
5. Allergy history
1. It would be greatly appreciated if you could monitor his/her
6. Conclusion condition (any special request). Your expert assessment and
management will definitely benefit Mr/Mrs X for a speedy
recovery
2. All relevant documents are enclosed along with this letter for
your perusal. Should there be any queries, please do not hesitate
to contact me.
7. Closing Yours sincerely,
Doctor
Let's start our case note
Address
1. Doctor's name Dr Tony Jones
2. Speciality NOTHING GIVEN BUT SAID LOCAL DOCTOR
3. Name of the Hospital & address Private practice
12 New Street
Stillwater
4. Today's Date 18 May 2019
5. Dear (Doctor’s last Nm) Dear Dr Tony
6. Re: Pt name D.O.B/Age Re: Ms Betty Johnson, Age: 81 years
In letter, we will write,
Dr Tony Jones
Private practice
12 New Street
Stillwater
Date: 21.03.2015
Dear Dr Tony,
Re: Ms Betty Johnson
Introduction
You will select following particular from case note to arrange your
introduction part-
1. Patient's last name
2. Patient age (if not given u can calculate it from D.O.B)/ you can also avoid this. 3.
Profession
3. The patient’s final diagnosis and recovery status.
4. When the patient will be discharged.
In this case note-
1. Patient’s last name Ms Johnson
2. Patient's age 81 years
3. Profession Not given
4. Final assessment/ diagnosis/ recovery Right total knee replacement
5. Specific request Nill
For this case-
I am writing to update you about Ms Johnson, an 81-years-old widow, who is being discharged
today after an uneventful recovery from total right knee replacement surgery. Your further
follow up would be highly appreciated.
Body Part 1 (Admission status)
In this Case Letter-
1. Osteoarthritis since 2011, increase pain and immobility for last 3 years.
2. All necessary pre-operative investigations were done
3. On 25/02/2015, right total knee replacement was done.
4. Warfarin was stopped 5 days before and clexane was started
5. Post-operative medications include - paracetamol, morphine, cephalothin, clexane
So we can write-
Ms Johnson had been suffering from osteoarthritis since 2011 for which she had developed immobility
for the last 3 years. After doing thorough investigations, she was operated successfully for right total
knee replacement on 25/02/[Link] she was advised to stop warfarin and commenced on
clexane. Postoperatively she was managed well with paracetamol, morphine, cephalothin along with
clexane.
Body part 2 (Hospitalization condition)
Here post operative condition-
1. Wound condition- gradually healed without any complication
2. Investigation- all normal except Hb showing anaemia- blood transfusion followed by oral iron
sulfate
3. Mobility- gradually increased
4. 10 days later- clips removed and transferred to rehab where she became gradually independent
through different physical exercise
5. INR increased – decrease dose of warfarin and iron sulfate
Ms Johnson’s post operative condition was uneventful with gradual wound healing and increased
mobility. All her blood reports were normal except for low Hb level for which blood transfusion
followed by oral iron sulfate were given. On 06/03/15, all clips were removed and she was transferred
to rehabilitation centre for required physiotherapy where her mobility improved markedly and became
independent through different physical exercise. In addition, dose of warfarin and iron sulfate were
reduced due to increased level of INR.
Body Part 3( Today’s condition & Discharge plan )
In this case note-
1. Condition- good with no cardiac issue
2. Discharge plan-
• Home nursing assistance
• Medication- warfarin, Feratab, paracetamol, oxycodone
• Rehabilitation appointment – 2 weeks later
3. Request local Doctor for repeat FBE and INR
Today, Ms Johnson have recovered well with no cardiac abnormality. She has been discharged with
home nursing assistance and medications which include warfarin, Feratab, paracetamol and
oxycodone. Please note, her next appointment in rehabilitation centre was scheduled in 2 weeks.
Body Part 4(Personal, medical, social, drug, family, allergy Hx)
Here you r referring this patient to her local Doctor who already know the patient. So u
need not to write anything about her personal, family, medical, drug and allergy history.
Conclusion
You will select following particular from case note to arrange your
Conclusion-
1. It would be greatly appreciated if you could monitor his/her condition (any special request).
Your expert assessment and management will definitely benefit Mr/Mrs X for a speedy
recovery.
2. All relevant documents are enclosed along with this letter for your perusal. Should there be
any queries, please do not hesitate to contact me.
In this letter-
It would be greatly appreciated if you could monitor Ms Johnson’s condition and repeat FBE as well as
INR. Your expert assessment and management will definitely benefit Ms Johnson for a speedy
recovery.
All relevant documents are enclosed along with this letter for your perusal. Should there be any
queries, please do not hesitate to contact me.
Closing
Yours sincerely,
Doctor
NOW COMPLETE THE LETTER
Dr Tony Jones
Private practice
12 New Street
Stillwater
Date: 21.03.2015
Dear Dr Tony,
Re: Ms Betty Johnson
I am writing to update you about Ms Johnson, an 81-years-old widow, who is being discharged today
after an uneventful recovery from total right knee replacement surgery. Your further follow up would
be highly appreciated.
Ms Johnson had been suffering from osteoarthritis since 2011 for which she had developed
immobility for the last 3 years. After doing thorough investigations, she was operated successfully for
right total knee replacement on 25/02/[Link], she was managed well with
paracetamol, morphine, cephalothin along with clexane.
Ms Johnson’s post-operative condition was uneventful with gradual wound healing and increased
mobility. All her blood reports were normal except for low Hb level for which blood transfusion
followed by oral iron sulfate were given. On 06/03/15, all clips were removed and she was transferred
to rehab where her mobility improved markedly and became independent through different physical
exercise. In addition, dose of warfarin and iron sulfate were reduced due to increased level of INR.
Today, Ms Johnson have recovered well with no cardiac abnormality. She has been discharged today
with home nursing assistance and medications which include warfarin, Feratab, paracetamol and
oxycodone. Please note, her next appointment in rehab was scheduled in 2 weeks.
It would be greatly appreciated if you could monitor Ms Johnson’s condition and repeat FBE as well as
INR. Your expert assessment and management will definitely benefit Ms Johnson for a speedy
recovery.
All relevant documents are enclosed along with this letter for your perusal. Should there be any
queries, please do not hesitate to contact me.
Yours sincerely,
Doctor
