Start from the reader, not from the notes
The case notes are longer than your letter should be. They usually contain more than the reader needs, on purpose. Part of the task is to decide what to leave out. Two criteria look at this: Content asks whether the reader gets everything they need, accurately. Conciseness and clarity asks whether you left out what they do not need and summarised well.
So do not start by reading the notes line by line. Start with the task instructions and answer four questions.
- Who is the reader, and what is their role? A cardiologist, a community nurse and a school teacher need different things.
- What does the reader already know? A GP who sees the patient every month does not need the full medical history again.
- What is the purpose? Referral, transfer, discharge, update or advice.
- What will the reader do next? Every note you include should help with that next step.
Three kinds of notes
Most notes fall into one of three groups. The middle group needs the most thought.
| Group | What it means | Example (discharge to a community nurse for wound care) |
|---|---|---|
| Essential | The reader cannot do their job without it | Wound site and size, dressing type, how often to change it, signs of infection to watch for |
| Relevant with context | Useful only if you explain why it matters | 'Lives alone' matters because nobody else can help with dressings; 'type 2 diabetes' matters because it may slow healing |
| Irrelevant | Does not affect this reader's task | A tonsillectomy in childhood, a hobby, a complaint about car parking |
A note can move between groups when the reader or purpose changes. Smoking history is essential for a respiratory physician, relevant with context for a wound-care nurse (smoking slows healing), and usually unnecessary for a school principal.
Group similar items
Notes often list the same kind of information on different dates. The reader does not need each entry. Put similar items together in one sentence.
Notes show missed clinic appointments in March, May and August
She did not attend her appointment in March. She also missed her appointment in May. In August she did not come to the clinic again.
She has missed three of her last four clinic appointments.
Why: One sentence gives the pattern, which is what the reader needs.
Several stable medical conditions
He has hypertension. He also has high cholesterol. He has had gout since 2015.
His other medical conditions, hypertension, high cholesterol and gout, are well controlled.
Why: Grouping shows the reader these are background problems, not the reason for the letter.
Summarise the history
Day-by-day progress notes are useful for the ward team but rarely for your reader. Tell the story in one or two sentences: where things started, what was done, and where things are now.
Five days of progress notes for a patient with a kidney infection
On day 1 she had a fever of 39.1°C. On day 2 she started IV antibiotics. On day 3 her fever settled. On day 4 she was eating well. On day 5 she changed to oral antibiotics.
Her fever settled after two days of intravenous antibiotics, and she has now been switched to oral antibiotics to complete a seven-day course.
Why: The reader learns the response to treatment and what is still happening. The daily details are not needed.
Transfer the facts accurately
A sentence can be grammatically correct and still change the meaning of the notes. This affects Content. Check these points carefully.
| Note says | Inaccurate letter | Accurate letter |
|---|---|---|
| Lives with son | She lives near her son. | She lives with her son. |
| Ramipril started 3/10 | Ramipril will be started. | Ramipril was started on 3 October. |
| Sutures removed day 10 | Sutures are due for removal. | Her sutures were removed on day 10. |
| Plan: review in 2/52 | He was reviewed after two weeks. | He is due for review in two weeks. |
| Nil known allergies | He has no allergies. | He has no known allergies. |
Worked example
Task: you are a hospital doctor. Write to Mrs Larsen's GP about her discharge today and the follow-up she needs.
Mrs Ingrid Larsen, 74 Social: widow, lives alone, 2nd-floor flat, no lift. Son visits wkly. Enjoys crosswords. PMH: T2DM (metformin), HTN, appendicectomy 1972, cataract surgery R eye 2019 14/10 Adm: L lower leg red, swollen, warm. T 38.4. WCC raised. Dx cellulitis. IV flucloxacillin. 15/10 Complained hospital food bland. 16/10 Redness reducing. Afebrile. 17/10 Changed to oral abx, 5 more days. Mobilising with stick, slower than usual. Managed stairs with physio. BGLs 12-15 mmol/L during adm. HbA1c 8.9%. Plan: GP r/v 1 wk: leg, BGLs, consider diabetes meds review.
| Note | Decision | Reason |
|---|---|---|
| Cellulitis, IV then oral antibiotics, 5 more days | Include | The GP needs the diagnosis, treatment and when the course ends. |
| Redness reducing, afebrile | Include, summarised | Shows a good response in one phrase; daily details are not needed. |
| BGLs 12-15, HbA1c 8.9% | Include | Directly linked to the request to review her diabetes medication. |
| Lives alone, 2nd floor, no lift, walking more slowly | Include, with context | Relevant to the GP's review of how she is coping at home. |
| T2DM, hypertension | Include briefly | Diabetes matters for infection and healing; the GP knows both conditions, so no detail. |
| Appendicectomy 1972, cataract surgery 2019 | Omit | Old and unrelated to the purpose. |
| Enjoys crosswords, food complaint | Omit | Do not affect her follow-up. |
| Son visits weekly | Optional | Brief mention is reasonable if you discuss support at home. |
On 14/10 she was admitted with red swollen warm L leg, T 38.4, WCC raised, and she was given IV flucloxacillin and on 16/10 the redness was reducing.
Mrs Larsen was admitted on 14 October with cellulitis of her left lower leg, which responded well to intravenous antibiotics, and she will complete a further five days of oral antibiotics at home.
Why: Full sentence, summarised progress, and the fact the GP must know: the course is not finished.
Check yourself
4 quick questions. Tap an answer to see why.
1 What should you do before reading the case notes in detail?
2 You are discharging a patient to a community nurse for daily dressings. The notes say 'Lives alone'. What is the best approach?
3 The notes say 'Metformin ceased 12/9'. Which sentence transfers this accurately?
4 Progress notes cover six days of steady improvement. What does a strong letter usually do?