OUTPATIENT LETTER STANDARD

EXAMPLE LETTERS

1
Contents

1 Introduction 4
1.1 Purpose of the letters 4
1.2 Audience 4
1.3 How the letters were developed 4
2 Dietetics example 5
3 Rheumatology example 7
4 Orthoptic example 9
5 Gastroenterology example 11
6 Community paediatrics example 13
7 Plastic and reconstructive surgery example 15
8 Palliative care example 17
 

2
NHS Digital

This project was funded by NHS Digital. NHS Digital is the trusted national provider of high-­‐quality
information, data and IT systems for health and social care. NHS Digital collects, analyses and
publishes national data and statistical information as well as delivering national IT systems and
services to support the health and care system. The information services and products are used
extensively by a range of organisations to support the commissioning and delivery of health and
care services, and to provide information and statistics that are used to inform decision-­‐making
and choice.

The Professional Record Standards Body

The independent Professional Record Standards Body (PRSB) was registered as a Community
Interest Company in May 2013 to oversee the further development and sustainability of
professional record standards. Its stated purpose in its Articles of Association is: “to ensure that
the requirements of those who provide and receive care can be fully expressed in the structure
and content of health and social care records”. Establishment of the PRSB was recommended in a
Department of Health Information Directorate working group report in 2012.

Copyright

This document has been prepared by the Professional Record Standards Body (PRSB) on behalf
of NHS Digital. You may use and re-use the information featured in this document (not including
logos or images) free of charge in any format or medium, under the terms of the Open
Government Licence. Any enquiries regarding the use and re-use of this information resource
should be sent to: enquiries@nhsdigital.nhs.uk. Where we have identified any third party copyright
material you will need to obtain permission from the copyright holders concerned.

Information and content © NHS Digital 2017.

Professional Record Standards Body

32-36 Loman Street,
London, SE1 0EH.
www.theprsb.org
support@theprsb.org
Community Interest Company No 8540834

3
1 Introduction
1.1 Purpose of the letters
These letters were developed as part of the Outpatient letter standard project. The purpose of
the letters is to demonstrate how the headings developed can be structured in different
services for different types of appointments.

1.2 Audience
The letters were created primarily for the NHS digital messaging team to use in the
creation of outpatient message specifications. As hospitals and GPs have different
structures for their EPRs, the project has developed standards for communication of
outpatient letters, ie a common standard to which local outpatient letter content can be
mapped to enable the meaning to be retained when communicated to the recipient (ie
semantic interoperability).

The examples provided are not intended as exemplars of the way in which outpatient
letters should be structured but simply to provide varied content to illustrate mapping to
the PRSB standard.

1.3 How the letters were developed

Clinicians from different specialties were asked to compose example outpatient letters to
represent different types of appointments (initial and follow-up, doctor, and AHP led
clinics) to demonstrate how the information might be best structured.

The letters were quality assured by the PRSB assurance committee.

4
2 Dietetics example

Community  Nutrition  and  Dietetics  Department,  Adobe  Health  Centre,  Donaldstown,  DO1  4XP   (01234)  567890  
Susan  Blight,  Community  Dietician   cndd@adobehc.nhs.uk

 
Patient  demographics   Attendance  details    
Patient  name   Mr.  Thomas    (Tom)   Date  of   01/05/2017  
Linacre   appointment/contact  
Date  of  birth   01/01/1960   Contact  type   First    appointment  
Gender   Male   Consultation  method   Face-­‐to-­‐face  
NHS  number   123456789   Seen  by   Susan  Blight,  Community  dietician  
Hospital  ID   TL98765     (01234)  569870  
Patient  address   29  Acacia  Road  BM9   Outcome  of  patient   Appointment  to  be  made  at  a  later  
6PL   attendance   date  for  follow-­‐up  by  telephone  
within  1  month.  
       
Patient  email   thomas@linacre.net   GP  Practice  details      
address  
Patient  telephone   077  7777  777   GP  practice  identifier   A111111  
number.  
    GP  name   Dr    C.  O’Reilly  
    GP  details   Canvas  Health  Centre,  27  Acacia  
Road,  BM9  6PM,  (01234)  956412  
 
 
Dear  Dr.  O’Reilly,  
 
Diagnoses:  Stroke   Problems  and  issues:  Acquired  swallowing  difficulties  
 
I  had  the  pleasure  of  meeting  Mr.  Linacre  at  the  Community  Nutrition  and  Dietetics  outpatient  clinic  on  1  May  
2017,  referred  by  Sugra  Bibi,  Hospital  dietician  at  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP.    
 
History  
Mr.  Linacre  attended  the  community  nutrition  and  dietetics  outpatient  clinic  for  review  of  feeding.  
 
Following  a  stroke  Mr.  Linacre  acquired  swallowing  difficulties.  During  a  recent  admission  to  hospital  Mr.  Linacre  
was  established  on  PEG  tube  feeding.  The  feeding  tube  insitu  is  a  15French  PEG  tube  placed  05/04/17.  The  
regimen  being:  1000mls  Energy  Multifibre  Feed  at  100mls/hours  for  10  hours  (9am-­‐7pm)  with  1400mls  water  
given  as  divided  flushes  (e.g.  10x140mls)  throughout  the  day  e.g.  before  and  after  feed  and  with  medications.    
His  weight  is  stable.    
 
Examinations  
Weight  80kg,  Height  175cm,  BMI  26cm/2,  
 
Clinical  summary  
The  estimated  nutritional  requirements  for  Mr.  Linacre  are  Energy  1500kcla/day,  Protein  80g/day,  Fluid  
2400mls/day.    
Mr.  Linacre  is  tolerating  his  feed  and  fluid  flushes  well  as  per  his  feeding  regimen  and  he  reports  taking  his  
medication.  Mr.  Linacre’s  peg  site  has  healed  and  was  clean  and  dry  and  exposed  (no  dressing)  on  assessment.    
Mr.  Linacre’s  bowels  are  opening  daily  (with  no  bowel  meds),  all  pressure  areas  are  intact  and  his  weight  is  
stable.      
5
  
Allergies  and  adverse  reactions:  No  known  allergies  or  adverse  reactions.  
 
Changes  to  medications  and  medical  devices  
(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
 
Medications  and  medical  devices    
(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
Medication  name   Energy  fibre  feed  (ACBSinicator  of  dysphagia)  
Form   Liquid  
Route   Enteral  
Site   PEG  
Method   Pump  
Dose  amount   100mls  
Dose  timing   Per  hour  for  10  hours  daily,  9am-­‐7pm  
Additional  instructions   1400mls  water  given  as  divided  flushes  (e.g.  10x140mls)  throughout  the  day  
e.g.  before  and  after  feed  and  with  medications.  
Medication  change  summary    
Status   Amended  
Reason  for  medication  change   Medication  to  be  ongoing  and  prescribed  by  GP  
Date  of  latest  change   01/05/17  
Medication  change   GP  to  prescribe  28  x  1000ml  bags  per  month,  ongoing.    
Comment/recommendation   Mr.  Linacre  has  been  supplied  with  a  feeding  pump.  Prescription  to  be  sent  
directly  to  the  feed  company  who  will  deliver  direct  to  patient.  
 
 
Actions  for  healthcare  professionals  
A  backpack  has  been  ordered  (05/05/17)  so  that  Mr.  Linacre  can  feed  when  he  goes  out  during  the  day  as  he  did  
not  like  feeding  during  the  night  when  he  was  in  hospital  and  feels  restricted  to  stay  at  home  at  the  moment.  
Feeding  Company  Nurse  (Doug  Sway)  has  been  requested  (05/05/17)  to  train  Mr.  Linacre  on  use  of  backpack.  
 
Actions  for  patient  or  their  carer    
Mr.  Linacre  has  been  asked  to  continue  on  feeding  regime.    
 
Information  and  advice  given    
Given  the  clinic  contact  details  and  a  copy  of  the  feeding  regime  with  Trust  guidance.  
 
Yours  faithfully,  
 
 
Person  completing  record  
Susan  Blight,  Community  Dietician    
Date:  06/05/17:  16:42  
 
 
Distribution  list:  
Mr.  Linacre  (patient),    
Doug  Sway,  Feeding  nurse,  Company    X  
Sugra  Bibi,  Hospital  dietician,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP    
Dr.  Gerald  McManus,  Neurologist,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP  

6
3 Rheumatology example

Rheumatology  Department,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP   (01234)  567890  
Dr  H.H.  Crippen,  Consultant  Rheumatologist   rd@stcrispins.nhs.uk  
 
Outpatient  letter  to  General  Practitioner  
Patient  demographics   Attendance  details    
Patient  name   Miss  Ophelia  Gently   Date  of   11/05/2017  
appointment/contact  
Date  of  birth   01/04/1984   Contact  type   First  attendance  
Gender   Female   Consultation  method   Face-­‐to-­‐face  
NHS  number.   987654321   Seen  by   Dr.  H.H.  Crippen,  Consultant  
Rheumatologist  
Hospital  ID   TL98764     (01234)  569879  
Patient  address   22  Acacia  Road,   Outcome  of  outpatient   Appointment  to  be  made  at  a  later  
BM9  6PL   attendance     date  
Patient  email   ophelia@gently.net   GP  practice    
address  
Patient  telephone   077  7777  776   GP  practice  identifier   A111111  
number.  
    GP  name   Dr.    C.  O’Reilly  
    GP  details   Canvas  Health  Centre,  27  Acacia  
Road,  BM9  6PM  (01234)  956412  
 
Dear  Dr.  O’Reilly  
Thank  you  for  referring  Miss  Gently  to  my  rheumatology  outpatient  clinic.  
   
Diagnoses   1.  Multiple  joint  pain,    
2.  fatigue,    
No  evidence  of  inflammatory  arthritis.  
 
  3.  Type  1  diabetes  
4.  Hypothyroidism  
 
Clinical  summary  
Symptoms  are  unlikely  to  improve  until  sleep  disturbance  is  tackled.    I  suggest  Amitriptyline  is  prescribed.  
 
History  
Miss  Gently  has  had  left  wrist  pain  since  December  2016.  Since  then  she  has  also  had  right  wrist  pain  and  aching  
in  the  shoulders  and  knees.  She  describes  tingling  and  burning  in  the  forearms  and  in  the  calves  and  shins.  Her  
symptoms  are  gradually  worsening  and  they  are  now  constant.  She  feels  tired  all  the  time  and  has  broken  
unrefreshing  sleep.  She  has  been  diagnosed  with  Type  1  diabetes  and  hypothyroidism.  

Allergies  and  adverse  reactions   No  known  allergies  or  adverse  reactions  

Participation  in  research  

Name  of  research  study:  APIPPRA  
http://www.kcl.ac.uk/lsm/research/divisions/diiid/departments/rheumatology/research/clinical/current/apippra/apippr

Social  context  
Occupational  history   Unemployed  
Alcohol  intake   10-­‐12  units  weekly  
7
Smoking   Ex-­‐smoker  

Review  of  systems  

Poor  sleep.    

Examination  findings  
Musculoskeletal  system   Trapezius  discomfort  on  elevation  of  the  shoulders.  Discomfort  on  active  
neck  movements.  

Patient  and  carer  concerns,  expectations  and  wishes  

I  just  want  to  stop  hurting  all  the  time  and  to  have  some  energy  back.    

Investigation  results    
Investigation:   Investigation  result:  
Antinuclear  antibodies   Normal  
Complement  levels   Normal  
Immunoglobins   Normal  

Medications  and  medical  devices  

(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
   
Medication  name   Amitriptyline  
Form   Tablet  
Route   Oral  
Dose  amount   1  x  10mg    
Dose  timing   Once  per  day  
Additional  instructions   To  be  taken  one  hour  before  bed  
Status   Added  
Start  datetime   11/05/17  
End  datetime   23/05/17  
Indication   Sleep  disturbance  
Link  to  indication  record    
Comment  /  recommendation     Titrating  upwards  according  to  response  and  tolerance.    
  Patient  given  2xweek  prescription  in  clinic.  GP  to  please  review  in  2xweeks  
and  renew  or  amend  prescription  as  necessary.  

Plan  and  requested  actions      

 
Actions  for  patient  or  their  carer  
Should  endeavor  to  take  regular,  gentle  exercise  in  gradually  increasing  amounts.    

Information  and  advice  given  

The  patient  was  advised  that  previous  abnormal  blood  results  are  not  of  any  clinical  significance  other  than  
reflecting  known  diagnosis  of  thyroid  disease.    
 
 
Person  completing  record:    
Dr.  H.H.  Crippen,  Consultant  Rheumatologist,  GMC:  2639598,  Hawley.crippen@nhs.net  
Date:  11/05/2017:  14:38  
 
 
Distribution  list:  
Miss  Gently  (patient),    
8
4 Orthoptic example

Ophthalmology/orthoptics  clinic,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP   (01234)  567890  
Rupert  Rigsby,  Orthoptist   orthde@stcrispins.nhs.uk  
 
Outpatient  letter  to  General  Practitioner  
Patient  demographics   Attendance  details    
Patient  name   Mr.  Reginald  Perrin     Date  of   19/05/2017  
appointment/contact  
Date  of  birth   01/04/1983   Contact  type   First  attendance  
Gender   Male   Consultation  method   Face-­‐to-­‐face  
NHS  number.   982354321   Seen  by   Rupert  Rigsby,  Orthoptist  
Hospital  ID   TL23764     (01234)  569879  
Patient  address   5  Acacia  Road,  BM9   Outcome  of  patient   Discharged    
6PG   attendance  
Patient  email  address   reginald@perrin.net   GP  practice    
Patient  telephone   077  6677  7766   GP  practice  identifier   A111111  
number  
    GP  name   Dr.    C.  O’Reilly  
    GP  details   Canvas  Health  Centre,  27  
Acacia  Road,  BM9  6PM  (01234)  
956412  
 
Diagnoses   Right  IV  cranial  nerve  palsy  
 
Dear  Dr.  O’Reilly,  
 
I  had  the  pleasure  of  meeting  Mr.  Perrin  in  the  orthoptic  outpatient  clinic  today,  referred  by  Michael  
McMonagle,  Occupational  Therapist,  Head  Injury  Team,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP  
 
History  
Diplopia  and  ocular  motility  defect  

Allergies  and  adverse  reactions   No  known  allergies  or  adverse  reactions  

Examination  findings  
Ocular  motility  testing   Right  hypertropia  

Procedures   Fitted  a  prism  on  patient’s  glasses  (right  side)  

Clinical  summary  
Referred  from  the  head  injury  team  as  patient  experiencing  diplopia.  Diagnosed  with  a  right  IV  nerve  palsy.  
Fitted  a  prism  on  patient’s  glasses  to  relieve  diplopia.  

Plan  and  requested  actions      

 
Actions  for  healthcare  professionals  
Referred  to  ophthalmologist  by  Rupert  Rigsby  on  19/05/17  

Actions  for  patient  or  their  carer  

Patient  has  been  advised  to  inform  the  DVLA  regarding  the  diplopia  and  fresnel  prism  
 
9
Yours  sincerely  
 
 
Person  completing  record:   Rupert  Rigsby,  Orthoptist,  HCPC  no:  14569872   orthde@stcrispins.nhs.uk  Date:  
19/05/2017:  16:00  
Distribution  list:  Mr.  Perrin  (patient),  Michael  McMonagle,    Occupational  Therapist  

10
5 Gastroenterology example

Gastroenterology  Department,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP   (01234)  567890  
Dr.  Ruth  Jones,  Consultant  Gastroenterologist   gd@stcrispins.nhs.uk  
 
Outpatient  letter  to  General  Practitioner  
Patient  demographics     Attendance  details    
Patient  name   Ms.  Agatha  Critchard   Date  of   01/05/2017  
appointment/contact    
Date  of  birth   01/02/1964   Contact  type   First    appointment  
Gender   Female   Consultation  method   Face-­‐to-­‐face  
NHS  number.   124356789   Seen  by   Dr.  Ruth  Jones,  Consultant  
Gastroenterologist  
Hospital  ID   TL89765     (01234)  562170  
Patient  address   30  Acacia  Road,  BM9   Care  professionals  present   Mrs.  N  Bryant,  IBD  specialist  nurse  
6PL  
    Outcome  of  patient   Appointment  to  be  made  at  a  later  
attendance     date  
Patient  email   frances@delatour.net   GP  practice    
address  
Patient  telephone   077  1234  7777   GP  practice  identifier   A111111  
number.  
    GP  name   Dr    C.  O’Reilly  
    GP  details   Canvas  Health  Centre,  27  Acacia  
Road,  BM9  6PM  (01234)  956412  
 
Dear  Dr.  O’Reilly  
 
Diagnoses:  1.  Proctitis,  2.  dyspepsia   Problems  and  issues:  Bloody  diarrhoea,  weight  loss  
   
Thank  you  for  referring  Ms.  Critchard  to  the  gastroenterology  outpatient  clinic.  
 
History  
Ms.  Critchard  presents  with  ongoing  symptoms  of  bloody  diarrhoea,  weight  loss,  and  abdominal  discomfort  that  
are  unresponsive  to  treatment.    She  has  a  2  month  history  of  bloody  diarrhoea.  Her  bowels  open  5-­‐6  per  day  
with  1-­‐2  nocturnal  episodes.  Ms.  Critchard  has  experienced  weight  loss  of  1  stone  over  the  same  period.  She  
experiences  a  crampy  left  iliac  fossa  pain  intermittently.    
 
She  has  no  history  of  travel,  unwell  contacts  or  previous  similar  symptoms.  She  has  longstanding  mild  dyspepsia  
for  which  she  takes  antacid  as  necessary.  It  has  never  been  investigated.  
 
Family  history:  Ms.  Critchard  has  no  family  history  of  I.B.D.    
 
Social  context:    
Household  composition:  Ms.  Critchard  lives  with  her  boyfriend.    
Occupational  history:  Baker  
Smoking:  Ex-­‐smoker,  stopped  2  years  
Alcohol  intake:  10-­‐14  units  of  alcohol  per  week.  
 
Allergies  and  adverse  reactions  
Causative  agent:  amoxicillin    
Description  of  reaction:  urticarial  rash  in  the  form  of  a  generalised  severe  rash  
Probability  of  recurrence:  likely  
Date  first  experienced:  She  first  experienced  a  reaction  aged  12  
 
11
Examination  findings:  The  abdomen  was  found  to  be  soft  but  mainly  tender  in  the  left  iliac  fossa.  There  was  no  
guarding  or  rebound  and  bowel  sounds  normal.  
 
Investigation  results:  Faecal  calprotein  levels  were  247mcg/g  faeces  (normal  <50)    
 
Procedure      
Procedure:  Rigid  sigmoidoscopy.        
Comment:  Performed  to  the  limit  of  view  at  20cm.  It  showed  inflamed  and  ulcerated  mucosa  with  contact  
bleeding  to  about  15cm.  Proximally  appears  to  improve.  
 
Clinical  summary
Findings  are  suggestive  of  IBD.  Rigid  sigmoidoscopy  looks  like  Ulcerative  Colitis.  5ASA  treatment  commenced  
today  pending  further  investigation.  
 
Plan  and  requested  actions    
 
Actions  for  healthcare  professionals  
A  flexible  sigmoidoscopy  has  been  requested  on  an  urgent  basis  by  Ruth  Jones  on  01/05/17.  FBC,  U&E,  LFT  and  
CRP  are  to  be  measured,  the  patient  was  provided  with  a  form  at  the  appointment.  Stool  MC&S  plus  C.  diff  are  
to  be  taken,  the  patient  was  given  forms  and  collections  points  at  the  appointment.

Changes  to  medications  and  medical  devices  

(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  

Medications  and  medical  devices    

(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
   
Medication  name   Asacol  
Form   Tablet  
Route   Oral  
Dose  amount   3  x  800mg  
Dose  timing   Once  a  day  
Course  details    
Status   Added  
Start  datetime   01/05/17  
End  datetime   Ongoing  
Indication   Treat  symptoms  
Comment/recommendation   A  14xday  course  was  prescribed  in  clinic,  please  renew  in  2xweeks  time.  

Yours  faithfully,  
 
 
Person  completing  record  Dr.  Ruth  Jones,  Consultant  Gastroenterologist  Date:  01/05/17:  16:42  
 
Distribution  list:  Ms.  Agatha  Critchard  (patient)  

12
6 Community paediatrics example

Community  Paediatrics  Clinic,  Adobe  Health  Centre,  Donaldstown,  DO1  4XP   (01234)  567890  
Arnold  Rimmer,  Community  Paediatrician   cpc@nhs.uk  
 
Outpatient  letter  to  General  practitioner  
Patient  demographics     Attendance  details    
Patient  name   Miss  Mary  Jones   Date  of   01/05/2017  
appointment/contact  
Date  of  birth   01/02/2013   Contact  type   Follow-­‐up  
Gender   Female   Consultation  method   Face-­‐to-­‐face  
NHS  number.   124352319   Seen  by   Dr.  Arnold  Rimmer,  Consultant  
paediatrician  
Hospital  ID   TL56945     (01234)  564563  
Patient  address   31  Acacia  Road,  BM9   Care  professionals   Jenny  White,  Occupational  therapist  
6PL   present   Sarah  Hall,  Health  care  assistant  
    Person  accompanying   Sally  Jones,  mother  
patient  
    Outcome  of  outpatient   Appointment  to  be  made  at  a  later  
attendance   date  
Relevant  contacts   Sally  and  Ian  Jones   GP  Practice    
(parents)  
Patient  email   sally@jones.net   GP  practice  identifier   A111111  
address  
Patient  telephone   077  1234  7777   GP  name   Dr    C.  O’Reilly  
number  
Educational   Greenacre  School,   GP  details   Canvas  Health  Centre,  27  Acacia  
establishment   Donaldstown  DO5  6AA   Road,  BM9  6PM  (01234)  956412  
 
Diagnoses   Problems  and  issues  
1. Tonic-­‐clonic  seizures     1. Increased  tonic-­‐clonic  convulsions  
2. Gastro-­‐oesophageal  reflux     2. Problems  with  transport  to  school  
3. Spastic   quadriplegia   secondary   to   birth   3. Increasingly  tight  right  hip  
asphyxia    
4. Cortical  visual  impairment    
5. Bilateral  convergent  squint    
6. General  learning  difficulties  
 
Dear  Dr.  O’Reilly,  
I  had  the  pleasure  of  seeing  Mary  and  her  mother  Sally  in  my  outpatient  clinic  today.  
 
Clinical  summary  
Mary  attended  today  for  a  scheduled  review  of  tonic-­‐clonic  seizures  and  gastro-­‐oesophageal  reflux.  
 
Mary  has  been  well.  However  she  is  now  having  on  average  four  tonic-­‐clonic  seizures  a  day.  Her  mother  has  had  
to  give  her  rectal  diazepam  on  two  occasions  but  she  has  not  needed  to  go  to  hospital.  She  had  a  PEG  inserted  
in  April  2017  and  her  reflux  has  reduced  considerably  since  then.  She  has  increasing  spasticity  of  right  hip  and  
more  frequent  tonic-­‐clonic  convulsions.  

Allergies  and  adverse  reactions   No  known  allergies  or  adverse  reactions.  

Social  context    

13
Educational  history   Mary  started  at  Greenacre  School  in  September.  She  enjoys  it  and  the  teachers  are  
pleased  with  her  progress.    Her  mother  has  been  bringing  her  to  school  by  car  but  this  is  
becoming  an  increasing  problem  as  due  to  recent  changes  work  she  now  has  to  start  
work  at  8:30  AM.  Unfortunately  Mary  is  not  eligible  for  free  school  transport  until  she  is  
five  years  old.  The  home-­‐school  liaison  teacher  is  trying  to  come  to  an  agreement  with  
the  local  authority  to  enable  Mary  to  use  school  transport.    The  teacher  for  visual  
impairment  has  seen  her  in  school  and  recommended  that  she  use  large  print  books  
and  a  magnifying  glass.  

Review  of  systems  

Neurodevelopmental  assessment  
Mary  can  now  sit  unsupported  for  about  30  seconds.  When  lying  prone  she  can  draw  her  knees  up  underneath  
her  but  does  not  make  any  attempts  to  move.  In  clinic  she  was  able  to  complete  the  circle  and  square  form  
board  but  cannot  do  them  reversed.  She  can  say  10  words  with  meaning  and  her  mother  feels  she  can  
understand  far  more.  She  is  able  to  finger  feed  and  will  drink  from  a  cup  if  it  is  held  for  her.  She  is  becoming  
more  sociable  and  has  a  lovely  smile.  

Examination  findings  
Musculosketal  system  &  nervous   Mary's  ankles  both  dorsiflex  to  90°.    Her  hips  are  very  tight;  the  right  hip  
system   only  abducts  to  30°  and  the  left  hip  to  45°.  The  right  hip  has  deteriorated.  
Dental   No  evidence  of  dental  caries.  

Plan  and  requested  actions      

 
Actions  for  patient  or  their  carer  
Mrs.  Jones  to  contact  epilepsy  nurse  on  01226  730000  if  she  has  and  concerns  regarding  convulsions  and  
medical  change.  
 
 
Actions  for  healthcare  professionals  
Request  to  orthopaedics  for  early  appointment  for  advice  on   Dr.  Arnold  Rimmer,  01/05/17  
deteriorating  right  hip  
 
Letter  of  support  to  education  regarding  school  transport   Dr.  Arnold  Rimmer,  01/05/17  
 
Review  medication  with  Sally’s  mother  by  telephone  in  two  weeks.   Phil  Brown,  epilepsy  nurse  

Medication  and  medical  devices  

(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
Medication  name   Lamotrigine  
Form   dispersible  tablets  
Route   via  gastrostomy  
Dose   10mg  
Dose  direction   Twice  a  day  
Status   Amended  
Reason  for  medication   Increasing  tonic-­‐clonic  convulsions  
change  
Date  of  latest  change   01/05/17  
Medication  change   increase  to  10mg  twice  daily  
Comment/recommendation   14-­‐day  prescription  provided,  please  provide  a  new  prescription  on  
parent’s  request.  
Total  dose  daily  quantity   20mg  

 
Yours  sincerely  
14
  
 
Person  completing  record:   Dr.  Arnold  Rimmer,  Consultant  community  paediatrician;  Date:  01/05/17:  16:42  
 
Distribution  list:  Sally  &  Ian  Jones  (patient’s  parents);    
Dr.  Charlotte  Worth,  Consultant  orthopaedic  physician,  St.  Crispin’s  Hospital;  
Philip  Brown,  epilepsy  nurse,  St.  Crispin’s  Hospital  

7 Plastic and reconstructive surgery example

General  Plastic  Surgery  Clinic,  St  Crispin’s  Hospital,  Donaldstown,  DO1  4XP   (01234)  567890  
Shauna  O’Casey,  Consultant  Plastic  and  Reconstructive  Surgeon   cpc@nhs.uk  
 
Outpatient  letter  to  General  practitioner  
Patient  demographics     Attendance  details    
Patient  name   Mrs.  Sam  Beckett   Date  of   16/05/2017  
appointment/contact  
Date  of  birth   02/03/1973   Contact  type   First  attendance  
Gender   Female   Consultation  method   Face-­‐to-­‐face  
NHS  number.   126952319   Seen  by   Dr.  Shauna  O’Casey,  Consultant  
surgeon  
Hospital  ID   TL12945     Patricia  Kavanagh,  Skin  cancer  
specialist  nurse  
Patient  address   34  Acacia  Road   Care  professionals   Jane  Joyce,  HCA  
present  
  BM9  6PL   Outcome  of  outpatient   Appointment  to  be  made  at  a  later  
attendance   date  
Relevant   Mr.  Samuel  Beckett   GP  Practice    
contacts   (husband)  
Patient  email   sam@beckett.net   GP  practice  identifier   A111111  
address  
Patient   077  1234  7982   GP  name   Dr    C.  O’Reilly  
telephone  
number.  
    GP  details   Canvas  Health  Centre,  27  Acacia  
Road,  BM9  6PM  (01234)  956412  

Diagnoses    
1.  Lesion  on  forearm    
2.  Hypertension    

Dear  Dr.  C.  O’Reilly  

 
I  had  the  pleasure  of  meeting  Mrs.  Beckett  in  my  general  plastic  surgery  clinic,  referred  by  Dr.  William  Yates,  
Dermatology  Consultant,  St  Crispin’s  Hospital,  Donaldstown,  DO1  4XP  (01234)  567890  
 
Clinical  summary  
This  delightful  lady  has  presented  with  a  10  month  history  of  a  left  arm  lesion  that  is  rapidly  growing  and  will  
require  excisional  biopsy  to  confirm  the  nature  of  the  growth.    

Plan  and  requested  actions      

 
Actions  for  healthcare  professionals  
Added  to  waiting  list  for  excisional  biopsy  of  lesion  and  direct  closure  on  left  forearm  by  Dr.  Shauna  O’Casey  on  
15
16/05/17.  
 
Individual  requirements  
Polish  national  with  limited  English  -­‐  needs  an  interpreter  
 
History  
Potential  Squamous  cell  carcinoma  to  left  forearm.  Rapidly  growing  lesion  to  left  forearm  x  10  months.  Has  seen  
dermatologists  who  have  assessed  and  referred  on  to  Plastics  for  surgical  excision  and  possible  skin  grafting  
after  lesion  is  excised.  

Family  history  
Mrs.  Beckett’s  father  died  of  melanoma  at  62years  old.  
 
Examination  findings  
Mrs.  Beckett  is  well.  There  are  no  skin  lesions  to  the  body  other  than  left  forearm.  She  has  a  3x2cm  scaly  lesion  
which  is  centrally  ulcerated.  There  was  no  evidence  of  left  axillary  or  cervical  node  involvement.  
 
Allergies  and  adverse  reactions    
Causative  agent   Description  of   Type  of  reaction   Severity   Probability  of   Date  first  
reaction   recurrence   experienced  
Penicillin   Nausea  and   Intolerance/Adverse   Minor   Likely   4  years  ago  
vomiting  

Social  context  
Household  composition:  Mrs.  Beckett  lives  with  her  husband.    
Occupational  history:  Factory  worker  
Smoking:  does  not  smoke      
Alcohol  intake:    rare.  

Information  and  advice  given  

Patient  seen  by  the  skin  cancer  Specialist  Nurse  and  has  been  reassured  of  outpatient  unit  place.  
I  have  warned  her  of  the  risk  of  infection,  bleeding,  reoperation,  scarring,  wound  dehiscence  and  the  need  for  
dressings.    She  understands  this  and  is  happy  to  be  added  to  the  waiting  list.  
 
Yours  sincerely  
Person  completing  record:    
Dr.  Shauna  O’Casey,  Consultant  Plastic  and  Reconstructive  Surgeon  
Date:  16/05/17:  16:42  
 
Distribution  list:  
Mrs.  Beckett  (patient)  

16
8 Palliative care example

Department  of  Palliative  Medicine,  St  Crispin’s  Hospital,  Donaldstown,  DO5  7TP   (01234)  567890  
Dr.  Doris  MacKay,  Consultant  in  Palliative  Medicine   pm@stcrispins.nhs.uk  
 
Outpatient  letter  to  General  Practitioner  
Patient  demographics     Attendance  details    
Patient  name   Ms.  Margaret  Walker   Date  of   01/05/2017  
appointment/contact  
Date  of  birth   01/02/1964   Contact  type   First    appointment  
Gender   Female   Consultation  method   Face-­‐to-­‐face  
NHS  number.   12435111   Seen  by   Dr.  Doris  Mackay,  Consultant  in  
Palliative  Medicine  (01234)  562987  
Hospital  ID   TL89711   Person  accompanying   Ms.  Karen  Walker  (daughter)  
patient  
Patient  address   30  Acacia  Road      
Postcode   BM9  6PL   Outcome  of  outpatient   Appointment  made  for  01/06/2017  
attendance    
Patient  email  address   margaret@walker.net   GP  Practice      
Patient  telephone   077  1234  1111   GP  practice  identifier   A111111  
number.  
    GP  name   Dr    C.  O’Reilly  
    GP  details   Canvas  Health  Centre,  27  Acacia  
Road,  BM9  6PM  (01234)  956412  
 
Dear  Dr.  O’Reilly  
 
Diagnoses     Problems  and  issues  
1. Metastatic  renal  cell  carcinoma   1. Pain  
2. Secondary  liver  cell  carcinoma   2. Nausea  
3. Necrotic  subcutaneous  soft  tissue  nodule  (anterior  to  liver)   3. Fatigue  
4. Type  II  diabetes       4. Psychologically:  tearful  and  upset  
5. Osteoporosis    
6. Hiatus  hernia          
7. Vertigo    
   
I  had  the  pleasure  of  meeting  Ms.  Walker  at  the  palliative  care  outpatient  clinic  today,  referred  by  Susan  
Snodgrass  from  the  community  Macmillan  team,  Endowdown  Centre,  BM5  0TP  on  the  23  April  2017.  
 
History  
Ms.  Walker  was  referred  for  review  of  symptom  control.  She  has  been  on  pazopanib  since  May  2017.  
She  had  a  right  nephrectomy  for  clear  cell  renal  carcinoma  in  Sept  2016,  and  now  has  metastatic  disease.  
 
Pain:  Ms.  Walker  struggles  with  pain  predominantly  around  the  right  upper  quadrant  of  her  abdomen  and  this  
goes  all  the  way  round  to  the  back,  at  worst  described  as  10/10.    She  has  been  reluctant  to  take  full  dose  of  Co  
codamol  -­‐  she  intermittently  takes  one  tablet  at  a  time  (30/500mg).  According  to  Karen,  Ms.  Walker  clearly  has  
a  high  pain  tolerance  level  and  tends  to  underplay  her  symptoms.      
 
Fatigue:  Ms.  Walker  finds  herself  tiring  out  by  the  second  half  of  the  day,  particularly  if  she  has  done  a  bit  more  
than  usual  earlier  on.      
 
Psychologically:  According  to  Karen,  she  and  Ms.  Walker  have  been  intermittently  tearful  and  upset  given  news  

17
of  disease  recurrence  and  are  doing  their  best  to  deal  with  it.  Ms.  Walker  wasn’t  expecting  to  hear  about  cancer  
recurrence  in  such  a  short  period  after  her  surgery.  
 
Allergies  and  adverse  reactions  No  known  allergies  or  adverse  reactions.  
 
Patient  and  carer  concerns,  expectations  and  wishes  
Ms.  Walker  is  very  clear  that  she  wishes  to  have  as  much  detail  as  possible  and  asked  about  her  prognosis.  She  
does  not  wish  to  be  resuscitated  in  the  event  of  a  cardio  respiratory  arrest.  
 
 
Information  and  advice  given  
We  discussed  the  benefit  of  being  able  to  do  more  through  the  day  and  having  better  psychological  well-­‐being  
when  pain  is  better  controlled.  I  have  explained  how  we  would  use  long  acting  Morphine  preparation  along  with  
Oramorph  to  get  control  of  background  as  well  as  breakthrough  cancer  pain.  Given  the  degree  of  tenderness  
around  the  subcutaneous  nodule  on  the  right  upper  quadrant,  we  have  discussed  that  radiotherapy  may  be  
helpful  with  the  pain.  
 
We  discussed  that  Ms.  Walker’s  fatigue  is  part  of  the  cancer  presentation,  and  we  discussed  being  pragmatic  -­‐  
doing  activities  with  gaps  in  between  to  allow  herself  to  conserve  energy  whilst  pacing  herself  through  the  day.    
I  have  encouraged  her  to  cut  back  on  tasks  that  are  not  as  important  as  others  such  as  her  household  chores  
and  to  delegate  them  to  others,  such  as  family  where  possible.    We  acknowledged  that  this  is  a  significant  
change  in  her  lifestyle  given  that  she  was  independently  managing  everything  for  a  long  time.  
 
I  explained  that  while  the  speed  at  which  disease  recurrence  has  happened  doesn’t  bode  well,  we  will  need  to  
see  how  Ms.  Walker  is  likely  to  respond  to  potential  treatment  options.    We  are  likely  to  know  more  about  
prognosis  following  her  appointment  with  the  Oncologist  in  the  next  couple  of  weeks  -­‐  we  don’t  know  how  she  
will  respond  to  treatment  in  itself.  It  may  be  that  the  treatment  might  be  effective  but  that  she  might  not  be  
strong  enough  to  cope  with  it  on  a  long  term  basis;  however  we  are  hopeful  that  there  will  be  some  positive  
outcome  with  the  treatment.    I  have  encouraged  her  to  proceed  with  planning  ahead  and  deciding  about  what  
she  would  prefer  to  happen  irrespective  of  her  prognosis.  
 
I  have  agreed  that  Ms.  Walker’s  wish  not  to  be  resuscitated  in  the  event  of  a  cardio  respiratory  arrest  was  
sensible  and  advised  her  either  yourself  or  I  could  complete  a  community  DNACPR  form  in  the  near  future.  Her  
son  and  daughter  are  aware  that  she  could  have  an  appointed  LPA  on  matters  of  her  health  and  well-­‐being.  She  
is  considering  funeral  arrangement  plans.  
 
I  have  advised  that  Ms.  Walker  can  get  in  touch  with  me  if  there  are  any  concerns.  
 
 
Legal  information  
Lasting  Power  of  Attorney:  Ms.  Walker’s  son,  Timothy  and  daughter,  Karen  have  an  LPA  for  handling  her  
financial  matters.    
 
Plan  and  requested  actions      
Actions  for  healthcare  professionals  
Ms.  Walker  is  to  be  supported  to  complete  a  community  DNACPR  form  when  she  is  ready  (Doris  MacKay  or  Dr.  
C.  O’Reilly  depending  on  timing).  
 
Ms.  Walker  is  to  see  Professor  Hawkins  for  consideration  of  immunotherapy  as  it  is  hopeful  that  she  will  have  
some  benefit  from  this  treatment.  Currently  her  performance  status  is  around  1-­‐2.  
 
Professor  Hawkins  is  requested  to  consider  radiotherapy  to  help  with  pain  as  a  result  of  degree  of  tenderness  
around  the  subcutaneous  nodule  on  the  right  upper  quadrant.  
 
Kindly  arrange  for  a  blood  glucose  check  next  week  as  Dexamethasone  might  increase  her  BM  levels.  (She  is  

18
aware  that  this  is  likely  to  be  temporary  and  will  get  better  with  stopping  Dexamethasone).

Changes  to  medications  and  medical  devices  

Medications  and  medical  devices  
(only  changes  to  medications  and  medical  devices  as  a  result  of  the  outpatient  encounter  are  included)  
   
Medication  name   MST  
Form   Tablet  
Route   Oral  
Dose  amount   1  x  15mg    
Dose  timing   Twice  per  day  
Status   Added  
Start  datetime   11/05/17  
End  datetime   24/05/17  
Indication   Pain  relief  
Comment  /  recommendation   Please  renew  the  prescription  in  2xweeks.  
 
Medication  name   Oramorph  
Form   Tablet  
Route   Oral  
Dose  amount   2.5-­‐5mg  -­‐    
Dose  timing   As  necessary  
Additional  instructions   Not  to  be  taken  more  frequently  than  once  every  two  hours.  
Status   Added  
Start  datetime   11/05/17  
End  datetime   24/05/17  
Indication   Pain  relief  
Comment  /  recommendation   Please  review  the  prescription  if  necessary.  
 
 
Medication  name   Metoclopramide  
Form   Tablet  
Route   Oral  
Dose  amount   10mg    
Dose  timing   As  necessary  
Additional  instructions   Not  to  be  taken  more  frequently  than  three  times  a  day  
Status   Added  
Start  datetime   11/05/17  
End  datetime   24/05/17  
Indication   Nausea  
Comment  /  recommendation   Please  review  the  prescription  if  necessary.  
 
Medication  name   Dexamethasone  
Form   Tablet  
Route   Oral  
Dose  amount   4mg    
Dose  timing   Once  per  day  
Additional  instructions   To  be  taken  in  the  morning  
Status   Added  
Start  datetime   11/05/17  
End  datetime   15/05/17  
Indication   Increase  energy  levels  and  appetite  

Yours  sincerely  
 
19
  
Person  completing  record:  Dr.  Doris  MacKay,  Consultant  in  Palliative  Medicine01/05/17:  16:42  
 
Distribution  list:  Ms.  Walker  (patient)  
Professor  Hawkins,  Medical  Oncologist,  St  Crispin’s  
Mr.  Bromage,  Urologist,  St  Crispin’s  
Susan  Snodgrass,  Community  Macmillan  Team  

20