OET WRITING GUIDE

INTRODUCTION TO THE WRITING SUB-TEST

The writing sub-test is centered on writing a formal letter in response to a typical situation at your
workplace. The task consists of patient case notes and writing task instructions which you are required
to use to write a letter. The letter is usually a referral lette, but other types include a discharge letter, a
transfer letter or a letter to inform a or advice a caregiver.

Format of the Writing sub-test

There is only one writing task in the sub-test which is based on a set of case notes. You need to write a
letter to a specific recipient using clear and focused.

Timing
The writing sub-test is for 45 minutes. Out of the total time allocated, five minutes is allotted to reading
the case notes and writing task. During these initial five minutes, you are not allowed to write anything
on the question paper or your answer sheet. Once your reading time is over, you have 40 minutes to
write the letter.

Assessment criteria
Marking is done on six criteria which assess different aspects of writing in a healthcare environment. It is
important to understand what is expected for each criterion to determine how writing in OET can be
best match up to the assessors’ expectations.

Criterion 1: Purpose
Professionals in health care settings need to understand the purpose of written communication quickly
so this criterion tests whether you are able to make the purpose of the letter clear and immediately
apparent to the reader. This should also be carried through the rest of the document. It is not enough to
just include ‘referral’ or ‘transfer’ at the beginning as the purpose of the letter because this does not tell
the reader. What is expected for him or her with regard to the patient you are referring or transferring
your letter needs to indicate clearly why the patient is being referred or transfer to your reader so they
can act on the information appropriately.

To achieve a higher score in this criterion:

 Go through the case notes carefully to get a sense of why you need to refer or transfer the
patient to the reader.
 Mention the purpose of writing at the beginning of your letter so your reader does not need to
spend time searching for this information.
 Use most important case notes to elaborate on and support the purpose of your letter.
Criterion 2: Content
 Communicating the necessary information in handover document is important because it will
be used to perform care functions could impacts the patient directly. Therefore, this criterion
assesses your ability to include all of the key information and communicate it accurately. To do
this, think carefully about your audience and their role in the patient’s continued care. You need
to make sure you provide them with all the necessary information from the case notes. The
criterion also assesses the accuracy of information in your letter. Try not to change or
reinterpret information in a why which change the meaning, as this will causes you to loss
marks.
 To achieve a higher score in this criterion, you should:
 Have a good awareness of the reader of the letter. Consider whether your reader is aware of
the patient’s case and what is necessary for them to know for continued care on this case.
 Provide the information they need to ensure the recovery and care of the patient. In other
words, do not leave out important information that is necessary for the reader to know.
 Be accurate. Convey the information presented in the case notes without changing the meaning
in any way. You may paraphrase or summarise as long as this does not affect accuracy of
meaning.
 Avoid making interpretations or giving a diagnosis when it is not started in the case notes.
 Do not add anything extra to the case notes, even if your medical knowledge tells you
otherwise.

Criterion 3: Conciseness and clarity

Clear and concise communication is essential to the medical workplace because of the time
constraints in a healthcare environment. This criterion assesses your ability to convey
information efficiently and recognize irrelevant information. Remember that the OET task case
notes contain a lot of information, not all of which may be necessary for your reader to know
because it’s not relevant to their role in the patient’s care or because medical history if you
were writing to the patient’s medical history if you were writing to the patient’s regular GP
because they would already know these details.

To achieve a higher score in this criterion, you should:

 Leave out irrelevant information that could distract your reader from the main message.
 Convey the information your reader needs to know in the most efficient way possible.
 Summarise information from the case notes when necessary
 Avoid explaining key information in a complicated manner.
Criterion 4: Genre and style

Written documents in a healthcare setting are formal, professional and factual. They never
contain personal judgements or Opinions. Your letter must therefore reflect these features.

To achieve a higher score in this criterion, you should:

 Maintain a polite, formal tone.
 Avoid adding your own judgements and feelings about the case.
 Use medical terms appropriately, always considering how familiar your reader would be
with a particular term. We cannot assume that all medical professionals will be familiar
with all medical terms and abbreviations. If you are writing to a professional in the same
discipline then it is appropriate to use specialist medical terms and abbreviations, but if
your reader is from another discipline entirely, then you may need to explain terms and
avoid specialist abbreviations.
 Avoid misuse and overuse of technical jargon and abbreviations.
 Provide simple explanations if writing to a layperson like a caregiver, social worker or
parent.
In short, get a clear understanding of the reader and the purpose of your letter. this will
simplify tour choice of vocabulary and tone.

Criterion 5: Organization and layout

Organization helps keep communication clear and east-to-read. You need to organize your letter
in a way that helps the reader find important information as quickly as possible.

To achieve a higher score in this criterion, you should:

 Logically divide information into paragraph. However, avoid relying on a template or
pre-decided format for this. You need to engage with the case notes on Test Day to
decide the best organization for your letter.
 Order information in a way that is most suitable for your reader. This is not necessarily
the same order in which the information is found in the case notes.
 Highlight information that you think is important for the reader to know.
 Present your letter in an appropriate layout. There is a variety of accepted letter formats
used by health professionals in different local contexts. You do not need to use a
particular format in the OET Writing sub-test; just try to ensure that your letter is laid
out well and meets the needs of the particular task.
Criterion 6: Language
Using accurate language in workplace communication is important because it prevents
misunderstanding and helps the reader to clearly understand your message. The OET Assessor
will gauge whether you have used grammar, vocabulary, sentence structure, spelling and
punctuation accurately enough to get your point across effectively to your reader.

To achieve a higher score in this criterion, you should:

 Use appropriate vocabulary suited to the context of the task.

 Ensure the language you use serves the purpose of communicating your message, so
avoid using complicated sentences. grammar or linking words just to show that you
know them. Even if used accurately, unnecessarily complicated language will lead to
reduction in your score. Aim to make it easy for the reader to find the required
information.
 Avoid common spelling errors.
 Maintain one spelling convention (US/British English) throughout your letter.
 Punctuate sentences clearly.
 Use the last five minutes to check your work and correct any errors you notice.
 STRATEGIES
Introduction
You should certainly practice writing OET sub-tests before test day and it is a very good idea to use a
‘method’ while you practice and on test day.

 Read the TASK carefully

 Interpret case notes correctly

 Select relevant case notes

 Transform case notes accurately

 Organise your writing logically

Please note that this method is not necessarily step-by-step. You will need to refer back to each part of
the method a number of times throughout the duration of the test. Nevertheless, the method provides
a solid set of instructions that will help you to understand what you need to do on test day to improve
your chances of success on this sub-test.

Read the TASK

The OET Writing sub-test goes for 45 minutes of which the first five minutes is only for reading. The first
thing you should do during the five minutes reading time is read the TASK carefully. The TASK is located
at the bottom of the case notes and looks something like this:

TASK
Using the information in the case notes, write a letter to Ms Samantha Bruin, Senior Nurse at Greywalls
Nursing Home, 27 Station Road, Greywalls, who will be responsible for Mr Baker’s continued care at the
Nursing Home.

Usually, the TASK will provide you with:

 The recipient’s name

 The recipient’s position/profession

 The recipient’s place of work and address

 A reference to what type of letter you must write: referral, discharge, transfer or

 Information
You can also see or infer from the TASK whether the recipient knows the patient or whether you are
introducing the patient to the recipient for the first time. Knowing this information is critical for case
note selection. For example, in the TASK above, we can infer that Ms Bruin knows Mr Baker already.

Interpreting case notes correctly

Having read the TASK, you now know WHO you are writing to and WHY, so you should begin reading the
case notes, paying special attention to case notes that are pertinent to the TASK. The case notes will not
be written in perfect sentences and are somewhat challenging to understand. As such, you will need to
‘interpret’ them. It is critical that you interpret the case notes correctly because misinterpretations will
result in incorrect information being placed in your letter.

Sometimes the case notes will be written in short ungrammatical phrases, such as:

NURSING MANAGEMENT AND PROGRESS

Daily dressings surgery incision site

A case note may also use an abbreviation, such as:

DISCHARGE PLAN
Social worker organised 2-wk hire of walker

In addition, case notes may even include symbols such as arrows. For example:

PAST MEDICAL HISTORY

Eyesight ↓ due to cataracts removed 16 mths ago

It is also critical to pay attention to the sub-heading or category that a specific case note is under.

Compare these two case notes:

PAST MEDICAL HISTORY

hernia

ADMISSION DIAGNOSIS
hernia

There are important differences between a hernia mentioned in ‘past medical history’ and a hernia
mentioned in ‘admission diagnosis’.
Selecting relevant case notes
After you have read and correctly interpreted the case notes you will then need to think more carefully
about case note relevance. Considering the body of your letter should only be between 180 and 200
words, you simply cannot – and you certainly should not – include all of the case notes.

Again, you need to make sure you are writing a relevant letter, and that largely depends on the TASK.
Make sure you understand the TASK fully and you know who you are writing to and why. Write the
letter for – and only for – the recipient, keeping his or her needs in mind at all times. Selecting case
notes, however, is challenging because while some case notes will clearly be relevant and irrelevant,
others will be semi-relevant. You have to make decisions about which case notes to include and which
case notes to ignore. This is why practice is so important: By practicing the OET writing sub-test, you will
develop an understanding of how many case notes you should include in order to write an appropriate
length. You do not want to write a letter on test day that is well below or well above the word count.

Organising case notes logically and coherently

‘Organising case notes’ and the following step ‘transforming case notes’ happen simultaneously while
you write. In other words, as you organize case notes into logical paragraphs you will also be
transforming them into accurate sentences.

The structure of your letter is critical for success. In short, it needs to be ‘readable’, not just
grammatically, but it should flow from beginning to ending a coherent and logical way. Although there’s
no ‘set structure’ for OET writing, there are some guidelines that you should keep in mind when
organising your letter:

 The introductory sentence/paragraph should contain the reason why you are writing the letter
(i.e. refer, discharge, transfer) and the main medical issue. As a rule, important information
should be prioritized or brought to the top of the letter; don’t bury the important information
deep in the letter.

 Paragraphs should contain single ‘themes’. A paragraph should not contain mixed information; it
should be clear what the paragraph is about, not confusing.

 The internal structure of the paragraph should also flow from beginning to end. So, while your
whole letter should flow from beginning to end so should your paragraphs be structured
coherently.

You may want to spend a minute or two ‘planning’ your letter structure before you begin writing. Ask
yourself:

 What’s the most important issue?

 What’s the secondary issue?
 What else does the reader need to know?
Sketch out a simple paragraph structure before you start writing because once you start writing it’s very
difficult to restructure, for you are writing on paper not a computer.

Transforming case notes accurately

Grammatical accuracy accounts for 20% of your mark; however, if your grammar is incomprehensible
then it will affect much more than 20% of your overall grade. Consider the difference in meaning from
these three verb tenses:


Mr. Baker experiences migraines. (regularly)



Mr. Baker experienced migraines. (in the past)



Mr. Baker is experiencing migraines. (currently)

You need to transform case notes into grammatically accurate sentences so that the meaning is clear
to the reader and reflects the intended meaning of the case note.

You should also make sure that you include a range of different sentence types – some short, some
complex, some active, some passive; but remember that the aim is to not include various sentence types
but to communicate information as clearly as you possibly can that will require you to use varied
sentence types and grammar.

After you have finished your letter, give it a once over for any silly grammar mistakes. Many candidates
make mistakes with:



Singular and plural nouns (pimple vs pimples)


Countable and uncountable nouns (blood vs bloods)


Articles (a headache vs the headache)


Verbs (suffers from vs is suffering from vs has suffered from etc.)

Prepositions (please monitor for anaemia / he is on medication)
 WRITING Assessment Criteria and Level Descriptors
Band Purpose Band Content
Content is appropriate
to intended reader and
addresses what is
needed to continue
Purpose of document
7 care (key information is
is immediately
3 included; no important
apparent and
details missing);
sufficiently expanded
content from case
as required
notes is accurately
represented
6 Performance shares features of bands 5 and 7
Content is appropriate
to intended reader and
mostly addresses what
Purpose of document 5 case and reader;
2 is needed to continue
is apparent but not
care; content from case
sufficiently highlighted
notes is generally
or expanded
accurately represented
4 Performance shares features of bands 3 and 5
Content is mostly
appropriate to intended
reader; some key
Purpose of document 3 information (about case
is not immediately or to continue care)
1
apparent and may may be missing; there
show very limited may be some
expansion inaccuracies in content
2 Performance shares features of bands 1 and 3
Content does not
provide intended reader
Purpose of document sufficient information
is partially 1 about the case and
0 obscured/unclear what is needed to
and/or misunderstood continue care; key
information is missing
or inaccurate
0 Performance below Band 1
© OET – 2019
Conciseness & Clarity Genre & Style
Writing is clinical/factual and
Length of document is
appropriate to genre and
appropriate to case and
reader (discipline and
reader (no irrelevant
knowledge); technical
information included);
language, abbreviations and
information is
polite language are used
summarised effectively
appropriately for document
and presented clearly
and recipient
Writing is clinical/factual and
appropriate to genre and
Length of document is
reader with occasional,
mostly appropriate to
minor inappropriacies;
technical language,
information is mostly
abbreviations and polite
summarised effectively
language are used
and presented clearly
appropriately with minor
inconsistencies
Inclusion of some Writing is at times
irrelevant information inappropriate to the
distracts from overall document or target reader;
clarity of document; over-reliance on technical
attempt to summarise language and abbreviations
only partially successful may distract reader
Clarity of document is The writing shows
obscured by the inadequate understanding of
inclusion of many the genre and target reader;
unnecessary details; mis- or over-use of technical
attempt to summarise language and abbreviations
not successful cause strain for the reader
Organisation & Layout Language
Organisation and paragraphing
Language features
are appropriate, logical and
(spelling/punctuation/vocabulary/
clear; key information is
grammar/sentence structure) are
highlighted and sub-sections are
accurate and do not interfere with
well organised; document is well
meaning
laid out
Organisation and paragraphing
are generally appropriate, logical
and clear; occasional lapses of
Minor slips in language generally
organisation in sub-sections
do not interfere with meaning
and/or highlighting of key
information; layout is generally
good
Organisation and paragraphing
are not always logical, creating Inaccuracies in language, in
strain for the reader; key particular in complex structures,
information may not be cause minor strain for the reader
highlighted; layout is mostly but do not interfere with meaning
appropriate with some lapses
Organisation not logical, putting
strain on the reader; or heavy
Inaccuracies in language cause
reliance on case note structure;
considerable strain for the reader
key information is not well
and may interfere with meaning
highlighted and the layout may
not be appropriate
 WRITING Assessment Criteria and Level Descriptors
Criterion
Purpose
 Helps the reader get a quick and
precise sense of what is asked of
them
Content
 Considers necessary information
(audience awareness: what does the
reader need to know?)
 Considers accuracy of information
Conciseness & Clarity
 Considers irrelevant information
(audience awareness: what doesn’t
the reader need to know?)
 Considers how effectively the case
is summarised (audience
awareness: no time is wasted)
Genre & Style
 Considers the appropriateness of
features such as register and tone
to the document’s purpose and
audience
Organisation & Layout
 Considers organisational features
of the document
Language
 Considers aspects of language
proficiency such as vocabulary,
grammar, spelling, punctuation
© OET – 2019
Description
Due to time constraints, health professionals want to understand the purpose behind a written handover document (e.g. referral
letter) very quickly and efficiently. This criterion therefore examines how clearly the writing communicates the purpose of the
document to the reader. The purpose for writing should be introduced early in the document and then clearly expanded on later
(often near the end of the document). The purpose should be easily and immediately identifiable to the reader, so there is no need
to search for it.
For example, a writer might at the beginning of the letter write ‘I’m writing to you today to refer patient X who is now being
discharged from hospital into your care’. Later in the letter, specific instructions for the health care professional on continuing care
should be listed.
The content criterion examines a number of aspects of the content:
 All key information is included
 Information is accurately represented
Audience awareness is key here. The writing needs to be appropriate to the reader (and their knowledge of the case) and what they
need to know to continue care.
Health professionals value concise and clear communication. This criterion, therefore also considers:
 whether unnecessary information from the notes is included and how distracting this may be to the reader, i.e. Does this
affect clarity? Is there any information that could be left out?
 how well the information (the case) is summarised and how clearly this summary is presented to the reader.
Referral letters and similar written handover documents need to show awareness of genre by being written in a clinical/factual
manner (e.g. not including personal feelings and judgements) and awareness of the target reader through using professional
register and tone. The use of abbreviations should not be overdone thereby assuming common prior knowledge. If written to a
medical colleague in a similar discipline, then judicious use of abbreviations and technical terms would be entirely
appropriate, but if the medical colleague was in a totally different discipline, or a letter was from a specialist to a GP, more
explanation and less shorthand would be desirable. If the target readership includes the patient, the information must be
worded appropriately, e.g. minimising medical jargon.
Health professionals value documents that are clearly structured so it is easy for them to efficiently retrieve relevant information.
This criterion examines how well the document is organised and laid out. It examines whether the paragraphing is appropriate,
whether sub-sections within the document are logically organised and whether key information is clearly highlighted to the reader so
that it is not easily missed. The criterion also considers whether the layout of the document is appropriate.
Health professionals are concerned with linguistic features only to the extent that they facilitate or obstruct retrieval of information.
This criterion examines whether the language is accurate, used appropriately and whether it interferes with reading comprehension
or speed.
 Short Notes To Improve OET Writing
You may be a nurse, doctor, pharmacist, physiotherapist or optometrist but this page and all its 12
pages are for you. Although this page focuses more on Nursing, it has almost all that you need –
formats, vocabulary, passive voice, tense, connectors, corrections and a number of new phrases you can
try in your referral letters.

Many medical professionals have said that this website’s content is a treasure for them because it is
simple, constantly updated and of course, FREE.

Who should Read This Page?

1. If you do not know that “The patient has been adviced” is incorrect.

2. If you still think that the comma in “I am writing this letter to refer Ms Abigael, who is being
discharged…” is okay.

3. If you think that “the patient was undergone” is a correct usage.

4. If you think that Ms Roy and her baby are equally important in the sentence, “Ms Roy as well
her baby needs your service…”

Page Index

 Part 1 For Beginners

 Part 2 Grammar Correction

 Part 3 Expanding Notes

 Part 4 Passive Voice in OET Letters

 Part 5 Tense in OET Letters

 Part 6 Connectors

 Part 7 Abbreviation

 Part 8 New Phrases

 Part 9 Fresh Writing Tasks

1.1 Introduction

Most of the OET Letters are referral letters although a very few are addressed to the patient’s relatives
such as spouses or parents. In most cases, a medical professional writes a referral letter with a request
to take care of the patient who is being discharged. Here is a situation:

 You are a nurse and Mr Albin has been your patient since he was admitted on 12th March, that
is, a month ago.

 He has improved a lot since his admission and tomorrow he is being discharged. Mr Albin has
strongly recommended sending him home but his doctor has advised him to continue his
medicines for a month in a care centre.

 As Mr Albin is very old and has memory failure, you (the nurse in-charge) think that it is better
to send a nurse who could take care of Mr Albin.

 Unfortunately, your hospital doesn’t provide nurses for home-care so you have to find another
solution.

 You have been told that Aster Home Care is a reputed nursing agency that arranges nurses for
home-care.

 Upon your experience and consideration, you decide to write a referral letter to Aster Home
Care to send a nurse to Mr Albin’s home.

1.2 Letter Types

1. Transfer/ Request Letter

2. Discharge Letter

3. Advice/ Information Letter

All these 3 kinds of letters are common for all the professions. Now scroll down and have a look at some
very common letters (Nurses).

1.3 Parts of a Letter

In most cases, a referral letter has 12 – 13 parts, including the address, date, subject, salutation and
closing lines. Let’s have a look to different styles of each section which you can copy under various
situations.
Section 1 Address

The Director

Community Health Service

197 Wellington St, Perth WA

6000, Australia

Ms Andrea Jones

Senior Nurse

Bethesda Hospital

25 Queenslea Dr

Claremount, Australia

Mr Alex Jim

Physiotherapist

MMC Hospital

Section 2 Date

28 January, 2019

30th March, 2018

Section 3 Sub: /Re:

Re: Master Vamuge Obeki, DOB: 23 May, 2005

Re: Mr Oliver Ghosh, 28 years

Section 4 Salutation

Dear Ms Steven

Dear Dr Smith
Dear Mr Sainuddhin

Section 5 Introduction

Transfer/Request Letter

I am writing to request an emergency admission for Mrs Olsen who requires further support and
management from your facility. She has been visiting us since December 2007.

Advice/Information letter

All parents are informed of a sudden outbreak of dengue fever and subsequent body pain that is
rampant in the city. As many of our students have been diagnosed positive by our resident doctor,
parents are advised to follow the instructions given below.

Section 6 Primary Details (Information)

Master Vamuga was admitted to the Children’s Emergency Department on 15 July, 2009 with acute
meningoencephalitis as a complication of mumps.

Ms Thompson was admitted to our hospital three days ago with injured leg and foot following a fall.
In addition to this, she underwent routine blood investigations and wound-swab to check for
infection and hydrosol dressing for minimising exudation.

Ms. Tracy was brought to the hospital on 19 September 2009. During admission, she was suffering
from severe pain and tingling sensation because of the damaged nerve fibres in the spinal cord.
Consequently, loss of movement along with bladder and bowel incontinence were developed in her.
Inaddition, her body balance and walking ability also were impaired.

Section 7 Supporting Data (As of Primary Information)

Worthy to note, the patient has had diabetes for the past two years and was admitted in the
hospital due to high blood pressure in 1992.

Section 8 Diagnosis & Treatment

Presently, Ms Tracy recovers well and she walks with the help of her daughter. Except for her
irregular back-pain, the patient is doing well.
Section 9 Nursing Management

At present, she is recovering well and her vital signs are all within normal limits. She is being assisted
for activities of daily living and her wound site is being kept clean and dry as well.

Section 10 Additional Data

Master Vamuga lives with his parents in a rental house. They are refugees arrived to Australia from
Sudan in 2008 and have one more 2 year old child. In addition, they know only Dinka and Arabic. Now,
Mr Obeki attends English classes and understands spoken English. However, he has limited writing
skill and require a language interpreter. Master Vamuga’s parents stated that both children had some
kind of vaccination at birth however, the vaccination records have been lost.

Looking at the patient’s social environment, Ms.Tracy is a widow and lives with her daughter.

Section 11 Request

Kindly provide education to his parents regarding mumps vaccination schedules and recommended
vaccines for both children. Neurological check up is required for Vamuga. Currently, he is stable and
ready for discharge. His address is enclosed along with this.

In view of the above circumstances, it would be greatly beneficial if you could arrange someone who
can help this family. Kindly help her for meeting hygienic needs as she is being affected with loss of
bowel and bladder control. Your special attention is brought to the point that you will have to do the
needful to assist her in order to improve her mobility.

Section 12 Closing

If you have further queries,please do not hesitate to contact me.

Section 13 Signing

Yours Sincerely,
1.4 Organizing
Charge Nurse
 1. Organising

To convert the case notes into a referral letter, you need to organize them into the following sections.

Whom are you To a medical professional like a doctor, a physiotherapist, a nurse, etc.
writing to?
To the patient’s next to kin like husband, wife, parents, children, etc.

Who are you A patient after operation, a patient on discharge, who needs further care.
referring /
transferring /
discharging?

Patient’s medical Date of admission

history
Initial diagnosis

Tests & surgeries (MRI/CT/Operation)

Patient’s diagnosis What tests have been done to diagnose the patient.
and treatment.
What is the treatment regimen.

Nursing How is the patient going to continue his further medication / treatment / follow
management. up.

Patient’s social Widow/widower/divorced

status
Lives alone.

Use simple present or present perfect tenses.

What is your Transfer, continued care, physiotherapist, social worker.
request?

Who are you? Charge nurse

Head nurse
1.5 Letter Types – Transfer

Ms.Kenzy Jaida

Head Nurse

Royal Perth Nursing Agency

6 Selby Street – West Australia.

15 November 2009

Dear Ms. Kenzy,

Re: Mrs Catherine Tracy, DOB 14 November, 1963.

I am writing this letter to refer Mrs Catherine Tracy who needs further care and assistance at home. The
patient, is being discharged today after a good recovery from a serious spinal cord injury.

Ms. Tracy presented to the hospital on 19 September 2009. During admission, she was suffering from
severe pain and tingling sensation because of the damaged nerve fibres in the spinal cord. She
complained loss of movement along with bladder and bowel incontinence. Inaddition, her body balance
and walking ability were also impaired.

Presently Ms Tracy is recovering well and she walks with the help of her daughter. Except for her
irregular back-pain, the patient is doing well. Worthy to note, the patient has had diabetes for the past
two years and got admitted in the hospital due to high blood pressure in 1992.

Looking at the patient’s social environment, Ms.Tracy is a widow and lives with her daughter.

In view of the above circumstances, it would be greatly beneficial if you could arrange someone who can
help this family. Kindly help her for meeting hygienic needs as she has loss of bowel and bladder control.
Your special attention is brought to the point that you will have to do the needful to assist her in order
to improve her mobility.

If you have any queries, please do not hesitate to contact me.

Yours Sincerely,

Charge Nurse.

1.6 Introduction
 Here is a sample referral letter on discharge. You can see the

Receiver’s Ms Georgine Sharma,

Address
Resident Community Nurse,

Community Retirement Home

103 Light Street, Newtown

Date 14 June, 2018

Salutation Dear Ms Sharma

Subject RE: Mr Lionel Ramamurthy, aged 63 years

Discharge Mr Ramamurthy will be discharged tomorrow (11/2) from Newtown Public

Plan Hospital back into your care following a bout of pneumonia. He was

admitted with acute shortness of breath, wheezing, painful coughing, fever, sleeplessness
and general aches, and was hospitalised for seven days.

Mr Ramamurthy has made good progress overall and is no longer feverish with his
inflammatory markers having

normalised. He does, however, still have a dry cough. In addition, his

mobility has improved; he can now walk short distances without his

walking frame as well as use the shower and toilet independently.

Discharge Please make sure Mr Ramamurthy sits up as much as possible to ensure

Plan postural drainage. In addition, he will need to continue his deep breathing

and coughing exercises (he may also need paracetamol for his chest and

abdominal pain).

Discharge Mr Ramamurthy will also need to be kept warm and encouraged to drink

Plan plenty of fluids during his recovery period. His diet will also need to be

monitored as he did gain some weight during his stay.

If you have any questions, please do not hesitate to contact me.

Closing Yours sincerely,

Designation Charge Nurse

Part 2 – Common Errors & Corrections

An OET Letter should be 99% error-free but that is not very easy. As you know, many of you opt for OET
because of its relatively low requirement for English language expertise. However, we cannot hope to go
for the exam with an amputated, sleep deprived, ill language proficiency.

Blade-sharp grammar is important in reading, speaking and listening as well. If you don’t know that
“little” is equal to zero and “few” is close to “no”, you are bound to err in reading and listening where
these words are repeated.

Here are a few grammatical errors that many of the OETians commit in writing letters apart from
speaking, listening and reading.

01 Comma rules

Some of you may ask, “What! for a Comma?” Yes, that’s true.

Now, look at these sentences:

1. “I am writing to refer, Ms Oven who is being discharged and sent for continued follow up
care at your facility.”

2. “I am writing to refer Ms Oven, the only survivor of a motor mishap, as he is set to be

discharged for continued care at your facility.”

The comma in the first sentence is completely out of place and that can cost you heavily. The
commas in sentence 2 are correct because the part of it between the two commas is an adjective
clause. Please be careful about commas.

 The comma is the most frequently used punctuation mark within sentences. Used
correctly it allows the writer to separate a group of words or phrase from other parts of
a sentence. This is necessary in order to add useful information in a sentence. The
information can be added at the beginning, the middle or the end. However if commas
are not used or overused, the meaning can be affected and the flow of information
disrupted. By understanding the basic rules presented in this section you should be able
to develop a good understanding of how and when to use commas in referral letters.

 Rules of Usage 1. The Adverbial Phrase: The adverbial phrase can be used in referral
letters to provide information such as a time, place, context, emphasis or mood in the
sentence which is to follow and it is commonly separated by a comma
 Context: On examination, there was slight tenderness in the right fornix.
 Date: On today’s visit, the patient was pale and sweaty.
 Emphasis: Please note, the patient is allergic to penicillin.
  Mood: Unfortunately, the patient’s condition has worsened. Note, mood or comment
adverbs, such as unfortunately or regrettably convey the health professionals concern
toward the patient’s condition and are therefore effective ways of displaying emphathy.
 Contrast: The patient's condition has improved. However, a follow up visit is required.

Handy Hint: Do not put a comma between a subject and a verb or a verb and an object. 2.
Appositives: This is a noun or a noun phrase that is placed after another noun to explain or
identify it. It has a very important use in the introductory sentence of referral letters as follows.
Mr Smith, an 80 year old widow, was admitted to hospital with complaints of heart
palpitations.
o Thank you for seeing Jordan, a 10 year old boy who presented at my clinic today with a main
concern of pain in tooth 54.
o I am writing to refer Mrs. Bradley, a 42 year old married woman who is suffering from cancer.

3. Conditional Sentences: These sentences are frequently used in the conclusion of a referral
letter and the rules are as follows:
o Use a comma if the if clause is at the beginning of the sentence.
If you could take over her antenatal care,it would be much appreciated.
If you have any further questions regarding this patient, please don’t hesitate to call me.
o Don’t use a comma if the if clause is at the end of the sentence.
 It would be greatly appreciated if you could take over her antenatal care.
Please don’t hesitate to call me if you have any further questions regarding this patient.

4. Complex sentences:
o Use a comma if the dependent clause is at the beginning of the sentence.
In case of irritation, redness or swelling, please consult your doctor.

When the results become available, I will forward them to you.

Because of her deteriorating condition, the patient was admitted to hospital.
o Don’t use a comma if the dependent clause is at the end of the sentence.
Please consult your doctor in case of irritation, redness or swelling.
I will forward the results to you when they become available.
The patient was admitted to hospital because of her deteriorating condition.

5. Comma Splices: A comma splice is two sentences joined together with a comma, but no
conjunction. This is an error as the information must be either joined with a coordinating
conjunction such as and/but/or or a new sentence must be started.
o He does not have any dental experience, he is worried about the pain.(incorrect)
o He does not have any dental experience and he is worried about the pain.(correct)
o He does not have any dental experience. Therefore, he is worried about the pain.(correct)

6. Noun Clauses beginning with that should not be separated by a comma.

o It is also important to know, that a re-check is organised for the 31.5.2009 at 10:30 in order to
remove the suture. (incorrect)
o It is also important to know that a re-check is organised for the 31.5.2009 at 10:30 in order to
remove the suture.(correct)

7. Use commas to separate three or more words, phrases, or clauses written in a series. The
final word does not require a comma and it should be separated by a conjunction such as and
or or
o Mrs. Olsen has a history of hypertension, hypothyroidism, glaucoma for which she is on
regular medication. (incorrect)

Mrs. Olsen has a history of hypertension, hypothyroidism and glaucoma which is on regular
medication. (correct)

Quick Guide to Commas

1. Use commas to separate independent clauses when they are joined by any of these seven
coordinating conjunctions: and, but, for, or, nor, so, yet.
2. Use commas after introductory a) clauses, b) phrases, or c) words that come before the main
clause.
3. Use a pair of commas in the middle of a sentence to set off clauses, phrases, and words that
are not essential to the meaning of the sentence. Use one comma before to indicate the
beginning of the pause and one at the end to indicate the end of the pause.
4. Do not use commas to set off essential elements of the sentence, such as clauses beginning
with that (relative clauses). That clauses after nouns are always essential. That clauses following
a verb expressing mental action are always essential.
5. Use commas to separate three or more words, phrases, or clauses written in a series.
6. Use commas to separate two or more coordinate adjectives that describe the same noun. Be
sure never to add an extra comma between the final adjective and the noun itself or to use
commas with non-coordinate adjectives.
7. Use a comma near the end of a sentence to separate contrasted coordinate elements or to
indicate a distinct pause or shift.
8. Use commas to set off phrases at the end of the sentence that refer back to the beginning or
middle of the sentence. Such phrases are free modifiers that can be placed anywhere in the
sentence without causing confusion.
9. Use commas to set off all geographical names, items in dates (except the month and day),
addresses (except the street number and name), and titles in names.
10. Use a comma to shift between the main discourse and a quotation.
11. Use commas wherever necessary to prevent possible confusion or misreading.

Capitalisation
Correct use of capitals is an important area to master when writing referral letters. Study the
rules of usage below to ensure you meet the standard conventions.

Rules of Usage 1.
Medications and Diseases
o Capitals are required for proper nouns. Proper nouns include the brand name of a drug or
registered trademark of the manufacturer.

o The chemical constituent should be written in lower case.

o Names of diseases should always be lower case.

blood pressure

o Eponyms: Some medical conditions are named after the person who discovered it. In this case
the first word should be capitalised.

Parkinson’s disease
 ’s palsy
o Names of medical procedures do not require capitals.

-ray

o Body parts should always be lower case

2. Proper Nouns: Proper nouns name something specific as in the examples below. These
words must always be capitalised.
o Job titles

o Institutions

o Places including addresses

o Titles when they precede the name of a person

Nurse Jones is in charge of the patient's care.

3. Common Nouns: Common nouns do not name any specific institution, place, person or
profession. These words do not need to be capitalised.
o The patient was admitted to hospital.
o The patient does not have a family doctor.
o Steve is a teacher.
o Yoshiro is a doctor.
o Reza is a dentist.

4. Holidays, months, days of the week all need to be capitalised. However seasons do not.
o The baby was born on Christmas Day.
o The patient was admitted to hospital on January 12.
o Please come and see me on Wednesday.
o The vaccination will be available in spring.
5. The pronoun "I" must always be capitalised.
o It was I who treated the patient.

6. Capitalise the first word of a salutation and the first word of a complimentary close.
o Dear Dr. Jameson:
o Yours sincerely,
Corrected One
Original Letter
Mr Steven Hummings
Community Nurse
Community Health Centre
18 Gannon Parade Newtown24
January, 2015Dear Sir,Ref: Ms
Belinda Hoyle, 37 years
Ms Hoyle has been admitted to
our hospital on 21 January, 2015
due to atype 1
fracture 1mm above the left
elbow and minor
displacement withhumerus align
ed as a result of scooter
accident. On examination , she
had disorientation, dizziness
and nausea. Splint was applied
for four weeks.
After Correction Why?
Mr Steven Hummings The best practice is Re:
Community Nurse
Community Health Centre
18 Gannon Parade Newtown24
January, 2015Dear Sir,Re: Ms
Belinda Hoyle, 37-Year Old
Ms Hoyle was admitted to our
hospital on 21 January, 2015 due
to x type 1 fracture 1 mm above the
left elbow and minor
displacement of humerus alignment
as a result of scooter accident. On
examination, she was found
with disorientation, dizziness
and nausea for which she has been
made to wear splints.
Ms Hoyle has no evidenced
medical history . Nevertheless,
at present she has the problem
with weight loss and poor
appetite.
Ms Hoyle is married and she has
a daughter 4-year old who has
been hearing problem and has
weekly consultation
with Speech pathologist.
Her husband is not helping for
the childcare and housekeeping
works and also she has some
marriage problems. However,
she has been doing home
based business in partnership
with husband and also she likes
to do gardening.
Upon discharge she is stable and
she can do independently self
care activities. However ,
she need rest
and helps for the child care and
lifestyle assistance. Moreover,
she needs counselling for
the marriage issues.
It would be grately appreciated
if you can sent homecare nurse
for helping Ms Hoyle. I request
you to pleaseremind the patient
regarding appointment. Please
do not hesitate to contact me
for further queries.
Ms Hoyle has no evidenced medical
history. Nevertheless, at present
she has the problem with weight
loss and poor appetite.
Ms Hoyle is married and she has a 4
year old daughter who
has x hearing problem. The child
has weekly consultation with a
speechpathologist. Sadly
enough, her husband is not fond
of helping her with childcare and
housekeeping works owing to
marriage problems. However, she
has been doing home based
business in partnership with
husband.
Upon discharge, Ms Hoyle is stable
and she can do self care activities
independently. However,
she needsrest
and help for x childcare and lifestyle
assistance. Moreover, she needs
counselling for the marriage-related
issues.
It would be greatly appreciated if
you could send a home-care
nurse for helping Ms Hoyle. I
request you to remind the patient
regarding her future appointments.
Please do not hesitate to contact
me for further queries
Your’s Sincerely Yours sincerely,

Charge Nurse Charge Nurse

Part 3 Expanding Notes

Your skill to expand notes is very important. At times there are notes as short as two words, like, “being
discharged” or two pieces of sentences, like, “Completely dependent. Needs assistance.” In both cases,
an OETian should be good at expanding – not too long, not too short. In simple words, if there are five
words in the notes, try to expand to 15 or 20 words.

Below you will see a large number of common notes and their expanded form. Learn each line and
improve your skill.

Part 3 Expanding Notes

Expanding little lines and short phrases into perfect, full-fledged sentences is another task that an
OETian has to successfully carry out. While expanding notes, you will see a few questions like these
arise:

1. How much to expand?

2. What should be expanded?

3. What should not be expanded.

Suppose you are writing to a patient’s family doctor, how much should be told to the doctor? Certainly
we do not have to write all the past history of the patient as the doctor is aware of the patient’s medical
history.

Look at this sample:

Time allowed:

 Reading Time – 05 Minutes

 Writing Time – 40 Minutes

Read the case notes and complete the writing task which follows:
Case notes:
Wayne Tucker, a 27 year old, was admitted into the hospital of which you are charge nurse.
Patient Details:
 Name – Wayne Tucker
 Marital Status: Unmarried
 Admission Date: 4 September, 2016
 Discharge Date: 14 September, 2016
 Family: One elder brother (Melvin Tucker,
married with two children, lives in Sydney)
Nursing Notes:
One of his neighbors admitted him into the hospital
after he had been complaining of severe headache.
The patient was swaying to both sides while walking
due to extreme headaches and dizziness/vertigo.
Patient History
 Occipital headache (for the last 1 year,
August 2015 – August 2016)
 Irregular bouts of vomiting (for the past 5
months, April 2016 – August 2016)
 No history of seizures, no vision
disturbances.
 No fever, no paresis, no history of
tuberculosis.
 No allowing difficulties.
Post-operative Reports.
This letter calls your attention to a little complicated
case of Mr Wayne Tucker who was admitted to our
care on 4th September, 2016 with severe occipital
headache associated with unstable gait and
dizziness.
OR
Thank you for accepting the aforementioned
bachelor who requires continuity of care from your
service . He underwent craniotomy in view of his
cystic mass lesion and is recuperating well.
On his admission assisted by his neighbors, Mr
Tucker was found swaying to both sides while
walking. It was soon found out that the patient’s
irregular movement was caused by headache and
dizziness.
He has been suffering with the same headache for a
year and multiple irregular episodes of vomiting for
5 months respectively. Subsequently, physical
examination was performed in which no significant
abnormality was found. However, find out exact
diagnosis, certain diagnostic investigation like MRI
and CT of brain were done and they revealed the
current diagnosis. Following this, he underwent
surgery and his cystic mass has been removed.
Mr Tucker’s post-operative phases were
satisfactory. Besides, he made a good progress
  CT scan (taken after one month) doesn’t
show any presence of residual lesion.
Discharge Plan
The condition of the patient was normal at the time
of discharge. Recommended to contact Dr. Tiana for
further treatment.
Social Background:
Lives alone in an apartment (Kiol Apartment, 5/11
Stratfield Square, Sydney NSW 2136, Australia)
Writing task
Using the information given in the case notes, write
a letter to Dr. Tiana, Head of the Department,
BrainCenter, Alphon Star Hospital, Reserve Rd, St.
Leonards NSW 2065, Australia, who will be
responsible for Mr. Wayne Tucker’s continued care.
In your answer:
 Expand the relevant notes into complete sentences.
 Do not use notes form.
 Use letter format.
 The body of the letter should be approximately 180 – 200 words.
Expanded Notes
without any complication. Also, a CT was repeated
after a month and no lesion was identified in his
study. He is scheduled to be discharged today.
In view of the above, it would be greatly
appreciated if you could examine Mr Tucker and
manage his condition as deemed appropriate. All
pertinent documents obtained during his
confinement is enclosed.
 It may be of note that he lives on his own.
 Socially, Mr Tucker is a lone man who lives
in an apartment in Sydney.
Address Line
Dr. Tiana
Head of the Department
BrainCenter, Alphon Star Hospital
Reserve Rd, St. Leonards NSW 2065
Australia.
Notes
 Patient : Nimmy Isaac.
 Patient’s name – Mr Evans Roderick
 72 year old – Married woman
 Open heart surgery patient
 Chronic Obstructive Pulmonary Disease,
Anxiety
Social History
Notes
Lives at home with husband, Isaac.
The couple have been married 50 years.
Isaac is a decorated soldier who fought in World War
II.
Isaac attends RSL (Returned Soldiers’ League)
meetings and enjoys the camaraderie.
Faced cerebrovascular accident (CVA) some 2 years
ago.
Agile, mentally active, speech slightly slurred.
Sentence form
 I am writing to refer Ms Nimmy Isaac…
 May I refer Mr Evans Roderick to your
facility…
 Ms. Isaac is a 72 year old married woman.
 This is important to note that the patient
has had an open heart surgery recently.
 Additionally, the patient has chronic
obstructive pulmonary disease.
Sentence Form
Ms Nimmy lives at her home with her husband.
The two have been married for fifty years.
This may be noted that Mr. Isaac is a decorated
soldier who had fought in the World War II.
Besides, Mr. Isaac attends RSL (Returned Soldiers’
League) meetings and enjoys the camaraderie
Mr. Mabel suffered Cerebrovascular Accident (CVA)
some 2 years ago.
Although Mr. Mabel is agile and mentally active, his
speech has been found slightly slurred.
Complaining of severe illness. Apart from this, he has, on several
occasions,complained of severe illness.

Walks with limp – impaired balance. It is important to note that the patient walks with a
limp, possibly because of his impaired balance.

Fell off the stair – badly injured right knee Later he fell off the stair from a considerable
height and badly injured his right knee.

GP requested ‘Your Health Care Agency’ for dressing Now, the GP has requested the assistance of Your
and assisting in taking shower daily. Health Care Agency for dressing and assisting in
taking shower daily.

Ms Isaac also smoked for 40 years but gave it away in Looking at her family history, Ms. Isaac has been
2004. smoking for 40 years. However, she gave it up in
2014.

Her mother was overweight with high BP. Mother This is also to be noted that her mother was
died of Myocardial infarction at age 75 (20 years ago) overweight with high BP and died of myocardial
infarction at the age of 75.

Admitted: 10 days ago for a double by pass. All went Ms. Isaac was admitted 10 days ago for a double
well. Has been recuperating. bypass surgery and is recuperating post-operatively.

Anxiety The patient is suffering from severe anxiety.

Not sure how she is going to cope once discharged Therefore it cannot be assessed how the client is
from Hospital. going to cope with her anxiety after discharge.

Worried she will die like her mother. Probably she fears that she would meet with an
unexpected and premature death like her mother.
Visibly distressed. Please note that the patient shows such symptoms
that she is visibly distressed.

Has outbursts of crying. It has been noticed that the patient is habitual to
frequent outbursts of crying.

Regular absence from school dating back to time of He has been regularly absent from school dating back
father’s death. to the time of his father’s death.

Year 2 – 3 days  He was absent for 3 days in the year two.

 In the second year he had absented from the

school for 3 days.

Year 5 – 8 Days in first term. By the time he was in the fifth year, Tom had kept off
the school for 8 days in the first term alone.

Discharge Plan

Refer to Community Nurse for monitoring. Therefore I would like to refer Ms Adams to you for
her continued treatment and assessment.

Operation successful. The surgery was successful, especially regarding the

postoperative phase.

Has been using an oxygen concentrator; Since then she has been using an oxygen concentrator
to avoid any chances of misadventure.

To be issued with a rented portable oxygen The hospital shall issue a rented portable oxygen
concentrator on discharge. concentrator for the patient’s use on these fifty days.
Prescribed Lipotor Oral, using Ventolin when Apart from Lipotor oral, the doctor has prescribed
required; Ventolin as per requirement.

Taught postural drainage position and pursed lip Apart from the above mentioned awareness
breathing technique. programs, the patient has been taught postural
drainage position pursed lip breathing techniques.

Advised to quit smoking. In spite of the patient’s refusal, he has been advised
to quit smoking during the course of medication.

Prescribed Nicobate patches. Her doctor has prescribed Nicobate patches for
improving nocotine level in her body.

To be discharged tomorrow. May I bring to your immediate notice that the patient
is due to be discharged tomorrow.

Part 4 Passive Voice

You may have noticed that OET writing uses a lot of passive voice. We write “the patient was admitted
on 12th December, 2017” or “the patient was treated for three months.” Whatever be the reason,
passive voice makes OET Writing impressive.

You may still be confused about the use of present perfect (have been admitted / has been admitted)
and simple past (was admitted) in passive voice.

A simple past is used when the action (admitted / injected / treated / scanned) is done and its effect is
no more important. “Mr Sam Manjooran was admitted” means that Mr Sam’s admission and treatment
are all over while “Ms Monica Washer has been admitted” means Ms Washer is still not treated
completely or not yet discharged.

OET letters and passive voice are highly connected. Information such as admission, treatment, tests,
prescriptions and advice are mostly written in passive voice. Look at some of the examples:
Active Voice Passive Voice

The doctor has prescribed tripple dose of Tripple dose of paracetamol has been prescribed (we
paracetamol. know by whom)

The patient has requested help of a nurse. The help of a nurse has been requested by the
patient.

I am writing this letter to you to refer Mr Tucker for This letter is being written to you to refer Mr Tucker
his ongoing care. for his ongoing care.

The hospital admitted him 4 September 2016 with He was admitted to the hospital with swaying on
swaying on both sides while walking. both sides on 4 September 2016.

Passive Voice Correct Use

Active Voice Passive Voice

Doctor advised Ms Ezee to quit smoking. Ms Ezee was advised to quit smoking. (We don’t
write “by doctor” because it is understood)

Nurses fed Mr Sam through tube. Mr sam was fed through tube. (We don’t write “by
nurses” because it is understood.)

The hospital admitted Mr Sam Blessen on 12th Mr Sam Blessen was admitted on 12th December,
December, 2015. 2015.

(We don’t write “by the hospital)

Part 5 Tense in OET Letters

Each segment of an OET Letter is tense specific but we hardly noticed that. Here is what it roughly looks
like:

1. Starting – Present Tense

2. Medical history – Past Perfect & Simple Past

3. social history – Present Tense

4. Nursing Management – Past, Present and Future Tense.

Tense in OET Letters

Content Tense Sample Lines

Introducing the patient Simple Present “I write this letter to refer Ms

Shallot who has been under our
Present Perfect care following multiple
Present Perfect Continuous surgeries…”

Patient’s admission, Simple Past “Ms Shallot was admitted to our

care on 12th March, 2018…”
diagnosis, treatment. Present Perfect

Patient’s present condition Simple Present “Post-operatively Ms Sandra has

regained a satisfactory health.”
Present Perfect

Patient’s social circumstances Simple Present Mr John lives with his family –
wife and three children, the
eldest of which is seventeen
years and the youngest 3.

Request Simple Present For the above reasons, you are

requested to regularly monitor
Simple Future Ms Reena’s insulin intake.
Simple Present Tense

Simple present is mostly used in explaining a patient’s social history.

1. Ms Roy lives alone in a two bedroom apartment in the suburbs.

2. For the last three years Mr Sam smokes excessively.

Simple present is a safe way of combining past, present and future together.

1. A retired nurse, Ms Stallone self injects her medicines. (This sentence suggests that Ms
Stallone used to, still does and will continue injecting in the future, too)

Present Perfect Tense

Present perfect tense is used to explain the recent tests the patient has undergone, the recent
medications the patient has been prescribed, the patient’s medical history that has not ended so
far.

1. Ms Oven has a family history of osteoarthritis in particular and joint pains in general.

2. With regards to his medical and social history, he has been seen by many Physicians and
Psychiatrists, yet no noted improvements have been reported.

3. Since birth he has been taken care by his attendant Ms Jennifer.

4. She has been instructed to use arm slings and is completely restricted from weight lifting is
advised for 4 weeks.

5. In addition to this, Endocrinologist has advised her to maintain a chart of her blood sugar
levels.

In all the above quoted situations, has, has been, have and have been are used. In all those
situations, actions are initiated but not completed – at least the effects of the actions are prevailing.
Simple Past

Simple past is commonly used in the introduction, medical history and in the medical management
of the letter. Remember, if a particular date is given, never fail to put that in simple past.
Simple Past Vs Present Perfect
1. Ms Roy was admitted to our care on 12th December with severe abdominal pain.
Simple Past Vs Present Perfect

Simple past is used for actions that terminated in the past at a particular time.

 “Ms Ray was admitted on 12th May with complaints of…”

Present Perfect is used for actions that started but not completely ended.

 “He has been advised to undergo this surgery within three weeks.”

In the above sentence, the patient has not yet undergone the surgery although the doctor has
advised for surgery.

Take another example.

 “The patient has has undergone surgery and is recuperating well…”

In the above sentence, only surgery is done but has not terminated..

Past Perfect (Had)

Past Perfect or Had + V3 is used mostly in past medical history, that is, to express an action that
happened before another action.

1. Ms Roy had developed symptoms of uterus cancer before she had got her tests done.

Part 6 Connectors

Another important area of an OET Letter is Connectors. Using too many or too less connectors is not
advisable. In the long run, when you have written several letters, you tend to feel more comfortable
with any number of connectors and there are chances you end up writing so many connectors.

Position of Connectors

A very important trouble is regarding the placement of connectors. While some can be placed at the
start or in the middle, others can be placed only in the middle. There are a few that are placed at the
extreme end.

Your knowledge and confidence in English is admired but over dose Connectors will kill the Letter. You
may write 1 simple connector (like and, but, because, yet, so, etc) and 1 compound connector (like
however, besides, in spite of, for which, etc) in a single sentence. Also, avoid using a compound
connector in two adjoining sentences.
Here is an example for overdose Connectors in a sentence:

“I am writing to refer Clara, a 10th grade student who has been presented with peritonitis followed
by ruptured appendix for which she underwent appendectomy and is now seeking your home-care
based on the availability of which she will be discharged.”

Connector At Starting In the Middle At the End

Additionally Additionally, you can try No No

uniting the patient’s
family, especially his
brothers.

Although Although the patient has It is imperative that he undergoes a No

no family history of complete examination although the
tuberculosis, it is patient has no family history of
imperative that he tuberculosis.
undergoes a complete
examination.

Also Also, kindly monitor his Kindly monitor his blood-sugar No

blood-sugar levels daily levels also daily for a week.
for a week.

Apart from this Apart from this, it is Very rarely. You will have to
often noticed that the closely observe the
patient remains in patient’s social
seclusion for hours. behavior apart
from this.

As a result As a result, the patient Very rarely No

has recently contracted
Ebola virus and is now he
is undergoing blood
transfusion.
As a result of No The patient was in areas where No
which several cases of Ebola infections were
reported as a result which he has
recently contracted Ebola virus

As a result of this The patient was in areas No The patient has

where several cases of recently contracted
Ebola infections were Ebola virus as a
reported. As a result result this.
this he has recently
contracted Ebola virus.

As if / As if being haunted by The patient behaves as if he is being No

his past memories, the haunted by some spirit.
As though patient likes to remain
away from everyone.

As well as No The patient as well as his mother and For that reason, Ms
a brother ishypertensive. Roy was given
(A very confusing another
connector. When
analgesic, as well.
you “connect A
and B with as
well as in the
middle, B doesn’t
get equal
relevance to A)

At the same time At the same time, the No No

patient has been
recommended trying
warm water bath twice a
day.
Consequently Consequently, low This was followed by a week’s No
appetite was developed physiotherapy, consequently enabling
in Ms Roy. the patient to ambulate without a
walker.

Due to this The patient’s car collided No The patient is

with a cyclist and killed a experiencing a
30 year old man on the traumatic
spot. Due to this, the depressive
patient is experiencing a state due to this.
traumatic depressive
state.

Due to which No The patient has spent two quarters of No

his life in Siberia due to which he is
now homesick.

For this reason, For this reason, the The patient was
patient was advised to advised to consult
consult a psychiatrist. an optometrist for
this reason.

Hence No Ms Roy experienced cervical dilation No

but child birth was delayed, hence she
had to undergo emergency caesarean
section at 6.30.
However, However, Ms Tokya has No No
now improved and she
can manage her insulin
injections.

If If you think the patient You can encourage the patient to quit No
will improve through this drinking If you think she will improve
smoking cessation, you through this smoking cessation.
can encourage him to
quit drinking.

In addition to In addition to the above You are requested to arrange No

(this) mentioned tests, you are appointment for the patient with Dr
requested to arrange Smith on 4th February at 5.00 pm in
appointment for the addition to the above mentioned
patient with Dr Smith on tests,.
4th February at 5.00 pm.

In order to In order to assess the You may encourage him to actively No

patient’s progress, you participate in socializing with his old
may encourage him to friends in order to assess the patient’s
actively participate in progress.
socializing with his old
friends.

In spite of In spite of the The patient has have hardly improved No

continuous monitoring, over the past one week in spite of the
the patient has have continuous monitoring.
hardly improved over the
past one week.
Not only X, but Y Not only is the patient The patient is not only The patient is not
also. aggressive, (but) she is aggressive, but she is also extremely only
(also) extremely revengeful at times. aggressive, but she
revengeful at times. is at times
extremely
revengeful also.

On the other On the other hand, the No (Very rare) The

hand patient can ambulate patient can
freely. ambulate freely on
the other hand.

Otherwise Otherwise it can lead to It can otherwise lead to a prolonged The patient or her
a prolonged state of state of comma. close relative can
comma. administer the
insulin
injections otherwis
e.

So that not No

Therefore Therefore it is evident It is therefore evident that the patient No

that the patient will need will need another three week’s
another three week’s intensive care at your facility.
intensive care at your
facility.

The sooner, the The sooner the patient The sooner the patient gets No
better gets accustomed to the accustomed to the hospital
hospital environment, the faster will be her
environment, the recovery.
faster will be her
recovery.
Too __ to __ No The patient is too much addicted to
drugs tocease from the habit.

Unlike Unlike other members of No No

his family, Mr Kevin has
been very active on
social media.

Whereas No No

While Rare Ms Ophir’s right arm is in heavy No

bandage whileher right leg is
paralyzed.

Connecting Phrases – Addition

 Apart from the above mentioned medicines, the patient commenced on aspirin and paracetamol
500 mg.

 In addition to this, the patient has been advised to undergo a three week physiotherapy.

 Additionally,

 Not only the patient was a widower but also very asocial owing to his abnormalities.

 Furthermore,

 Also, you can contact the patient’s wife or brother Mr. Biju John on 9810740061.

Connecting Phrases – Contrast

 However, no expected result was found even after three weeks.

 On the other hand, the patient’s health deteriorated on the following days.

 In spite of all the attempts made by the nurses, the patient developed extreme bipolar symptoms.
Connecting Phrases – Reason

 The patient is not accompanied by a relative, hence the need for a nurse to monitor his daily
activities.

 Mr Roy has not been able to respond to the analgesics so his doctor has asked him to commence
Confusing Connectors
on another course of medicines.

 As well as – As well is not “and.” In the sentence “The patient was advised to take tab
paracetamol as well as aspirin,” only paracetamol is in focus. In this case, aspirin is not important.

 Hence is one of the most commonly misused conjunctions. We never begin a sentence with
hence. “The patient has repeatedly requested for an early discharge hence this decision from the
hospital to discharge her today.”

Connectors

Before Connecting After Connecting

His father understands spoken English. He has His father understands spoken English but has
limited skills in written English. limited skills in written English.

They are refugees from Greece. For the last five They are refugees from Greece now residing in
years they have been residing in Australia. Australia for the last five years.

During the hospitalization, the patient responded Although the patient responded well to the
well to the treatment. Unfortunately, for the past treatment during hospitalization, for the past 28
28 hours his condition has been unexpectedly hours his condition has been unexpectedly
unpredictable. unpredictable.

Mr Jenkin’s medical history reveals that he is a Mr Jenkin’s medical history reveals that he is a
known case of hypertension and gout. He is on known case of hypertension and gout for which
regular treatment for this. he is on regular treatment.

Part 7 Common Medical Abbreviations

There are two kinds of abbreviations in OET:

 1. Very common abbreviations that you can use in writing, like Dr Mr Ms Ref: ECG, etc.

2. Uncommon abbreviations that you cannot use in a letter like ↑ (increasing), ↓ (decreasing),
etc.

There are thousands of medical abbreviations but, luckily, you need not learn even 100 of them to
understand a case note. Here is a list of those abbreviations most often repeated in your case notes.

Abbreviations Meaning

↑ Increase in; Increasing; Elevate

↓ Decrease in; Decreasing

→ Leads to; Results in; Causes

< Less than

> More than

Ψ Psychiatry

+ Positive

? Possibility of something

General Abbreviations

ACAT Aged Care Assessment Team (Australian)

BiBA Brought in by Ambulance

D/W Discussed With

EBM Evidence Based Medicine

EBP Evidence Based Practice

MVA Motor Vehicle Accident

NCP Nursing Care Plan

S/B Seen By (“Seen by Dr. Smith”)

SOAP Subjective Objective Assessment Plan

AiN Assistant in Nursing

More Abbreviations

CNS Clinical Nurse Specialist

DON Director of Nursing

EN Enrolled Nurse

EEN Endorsed Enrolled Nurse

EN Nurse Educator

NP Nurse Pactitioner

NUM Nursing Unit Manager

PCA Personal Care Assistant

RN Registered Nurse

RM Registered Midwife

Part 8 Stylish Phrases

The thing is, assessors are fed up with our usual cliche phrases such as “however, even though, should
you require further information, …” You will not score much by using these words because 90% OETians
use those phrases. Please find some other phrases, like, “I reckon that you will be having further queries
about the patient or his past history not furnished in this letter… In that case I will be most obliged to
provide you with speedy information…” Such things. I am creating a list of such easy to learn phrases for
all of you. Have a nice time. See you tomorrow.

Opening Phrase

 May I bring to your kind attention the brief case-history and discharge plans of Ms Dona who
has been admitted here for her treatment for abdominal pains.

 I am writing this letter to request follow up care for Mr John who is recuperating after a
prolonged cardiac instability and two subsequent surgeries. The patient is being discharged in a
week’s time.

Primary Data

 It was quite unfortunate that Ms Joseph and her husband had to meet with an accident on a
road that has the reputation of zero accidents for a decade.

Supporting/ Additional Data

 Ms Narayan has been on a strict lifestyle to control her addiction to alcohol but for some
unknown reasons, she has not been able to make any headway.

 Mr John is an alcoholic and a chain smoker for the last fifteen years after his untimely
retirement from the army where he had served as a captain. Mr John was a difficult man in the
army and was a nuissance among his peers..

Request

 I look forward to your kindness that would warmly accept Ms Joseph into your reputed palliative
care.

Closing
 You are most welcome to ring me any time in case at any point of time you require any
additional query pertaining to the information of the patient.

 For the above reasons, you are requested to arrange Mr John’s further care as he is moving to
home in a week.

 I have all the reasons to believe that you will need to contact me several times to make fresh
inquiries about Mr John because this tough man will pop up with new issues for people who are
around him. Please feel free to contact me at any time of the night or contact one of our day
staff on the number you have recieved in the last mail.

 I reckon that you will be having further queries about the patient or his past history not
furnished in this letter… In that case I will be most obliged to provide you with speedy
information.
January 12 OET Official Exam Material (Close Reproduction)

You are the charge nurse at Aster Medicity, Sydney, and Mrs Fabiana Calton has been under your care.

Today’s date : 12 January, 2019.

Patient’s Name Mrs Fabiana Calton

Age 95 years

Diagnosis Right ankle fracture due to a fall.

DOA 1 January, 2019

Social Background Lives alone. Widow. 2 children.

Both live far away.

No strong social bonds.

Goes to church on special days.

Used to be a Social drinker; no smoking.

Medical background Repeated renal dysfunction since 1990.

Stressed after husband’s death in 1998.

Management and progress X-Ray revealed fracture in right ankle.

Applied POP.

Started antibiotic warfarin but stopped due to

overdose issue.

Started apixaban but stopped that too.

Now back on warfarin.

Physiotherapy started.
 Elevation to be continued.

Today’s nursing notes No noticeable progress and cannot move.

Plan She needs to continue physiotherapy after the

removal of POP.

Can take warfarin under properly monitored dose.

If not, apixaban can be started.

Physiotherapy to continue after removal of POP.

Reduce or stop use of walker.

Review for xray on 12th February.

Writing Task

Write a referral letter to Ms Lee Sterner, occupational therapist at Ave Well Being, 2323 Park Street,

Sydney, for Mrs Calton’s home management and medication monitoring until she is able to manage

herself.

In your letter:

 Expand the relevant notes into complete sentences.

 Do not use notes form.

 Use letter forma.

The body of the letter should be approximately 180 – 200 words

Answer

Ms Lee Sterner

Occupational Therapist

Ave Well Being

Sydney

12 January 2019

Dear Ms Lee Sterner,

Ref: Mrs Fabiana Calton, aged 95

I am writing to refer Mrs Fabiana Calton, who recovers from right ankle fracture, is being
discharged today for further home management and medication monitoring.

As part of management, it would be greatly beneficial if you could assist Ms Calton in taking
warfarin medication in the prescribed dose. You are free to medicate her with apixaban in case
overdose issues arise. It is important to note that she has to continue her physiotherapy even
after POP removal and you are expected to restrict her to walk. Please note that her review for
X-Ray will be on 12 February.

Mrs Calton was admitted to the hospital on 1 January 2019 with right ankle fracture. Her X-Ray
revealed the presence of fracture and plaster of Paris was applied over the right ankle.
Subsequently during her stay, she was commenced on medications such as warfarin which was
terminated due to overdose. Following this, she was given apixaban for a while but once again
she shifted to warfarin.

Regarding Ms Calton’s social environment, she is a widow and lives alone. She has had repeated
renal problems since 1990 and also she became stressed after her husband’s death. Presently,
Ms Calton has no remarkable recovery as evidenced by her difficulty in movement. She has been
advised to elevate the leg and to continue physiotherapy after the removal of the plastering.

Should you require any information regarding this patient, please do not hesitate to contact me.

Yours Sincerely,

Charge Nurse.
WRITING TEST

Time allowed:

Reading Time: 05 Minutes

Writing : 40 Minutes

Read the case notes and complete the writing task which follows.

Case Notes:

Samuel Zoel, a 63-year-old man, was admitted into the acupuncture hospital of which you are a head
nurse. The patient complained of chronic pain on both shoulders and around his neck.

Patient Details

Name: Samuel Zoel

Marital Status: Widower

Children: Jacob (Teacher at private school in London).

Kristina (married to Henry, runs a boutique shop, lives in Manchester).
Adla (works at IT Firm, married to Bill, lives in Sydney).

Admission Date: 29 June 2016

Discharge Date: 5 July 2016
Social Background

Lives in a care home (Max Care, London).

Likes gardening.
Actively involved in social services (teaches small children).

Patient History

Past Medical History

No history of any illnesses
Underwent successful acupuncture and cupping courses for shoulder pain and neck pain (first on 25
April 2016 and second on 27 May 2016) at a private acupuncture clinic. No side effects / no illness.

Underwent acupuncture and cupping course again in the month of June 2016.

Felt no discomfort during the procedure and went home after the treatment.

After three hours, the patient began to feel chest tightness, chest pain and heart palpitations.

The patient didn’t contact the doctor about these symptoms.

June 29 2016

His condition deteriorated with the emergence of extreme cold sweats and shortness of breath.

Shifted to hospital on the same day.

Physical examination:

Temperature - 36.2°C

Pulse rate - 140 times per minute

Respiratory rate - 40 times per minute

Blood pressure - 85/40 mmHg

Round visible ecchymosis on the skin on the neck and shoulder

Dull heart sounds

Percutaneous oxygen saturation - 76%

Cyanosis at skin and mucous membranes

Drum sound in percussion

Trachea in the middle

Reduced breathing exercises on both sides of the thorax

Moderate coma

Chest computed tomography showed a bilateral pneumothorax on both lungs (70% collapsed).

Treatment

Simple respirator assisted ventilation / endotracheal intubation were performed.

Operated a closed thoracostomy with standard chest drainage in the fifth intercostal space at the
midaxillary line, to treat the pneumothorax with bilateral thoracoscopy.

Result

The patient’s shortness of breath improved.

Percutaneous oxygen saturation returned to 96%.

30 June 2016

Transferred to ICU and given the treatments of mechanical ventilation, sedatives, analgesics and so on.
The patient finally recovered consciousness / showed obvious enhancement of breath sounds in both
lungs.

Bilateral chest drainage tube being pulled out.

1 July 2016

The patient was transferred into a general ward.

Discharge

The patient was in good condition at the time of discharge with no discomfort or feelings of pain.

Writing Task:

Using the information provided in the case notes, write a letter to head nurse, Sylvia Dian, at Max Care
Center, 1a Chase Side, London N14 5BP, UK who will be responsible for Mr Zoel’s continued care at the
home.

In your answer:

 Expand the relevant notes into complete sentences

 Do not use note form
 Use letter format.

The body of the letter should be approximately 180–200 words.

Answer

05 /August/ 2016

Ms Sylvia Dian

Head Nurse

Max Care Centre

La Chase Side

London N145BP

UK

Dear Ms Sylvia Dian,

Re: Mr Samuel Zeol, aged 63

Mr Samuel Zoel, who was treated for bilateral pneumothorax, is being discharged back to your
care, as he requires ongoing care to maintain his well being.

When Mr.Zoel was brought to the hospital on 29 June, 2016 he had severe cold sweats and
shortness of breath. He was found to be in moderate coma state with 76% of percutaneous
oxygen saturation. On physical examination, his vital signs were noted to be deranged. Cyanosis
over skin and mucous memberane and ecchymosis on the skin of neck and shoulder were noted.
In addition, dull heart sounds and reduced breathing on both sides of thorax were found on
auscultation . A computed tomography scan of chest revealed bilateral pnemothorax of the
lungs.

Mr Zoel’s condition was stabilised with simple respirator assisted ventilation. Inaddition a
closed thoracostomy was performed to treat pneumothorax and a chest drainage tube was
inserted. After the procedure it was noted that, his oxygen saturation retained to 96%. Also he
was treated with analgesics and sedatives. Later he gained consciousness and showed
enhancement of breath sounds in both lungs. Hence, he was shifted to a general ward after
removal of chest tubes. Currently, his symptoms and distress subsided.

In this regard, Mr. Zoel requires continued care from your provision to maintain optimal health
status.

Please do not hesitate to contact me for further clarifications.

Yours sincerely,

Head nurse
WRITING TEST

Time allowed : 40 minutes

Today’s Date

10/07/09

Notes

Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent admission to hospital.
You are the night nurse looking after her.

Patient Details

Address : Golden Pond Retirement Village

83, Waterford Rd, Annerley, 4101

Phone : (07) 3441 3257

Date of Birth : 29/01/1926

Marital Status : Widowed

Country of birth : Australia

Social History

Moved to Retirement Village following the death of husband in December 2007.

Next of kin : Son, Nicholas Olsen

53, Palmer Street, Warwick 4370

Ph (07) 4693 6552

Normally alert and orientated. Enjoys bridge, bingo and reading.

Medical History

Hypothyrodism since 1997

Hypertension since 2003
Glaucoma since 2004
Allergic to penicilin

Prescription medications

Karvea 150mg 1 daily

Oroxine 0.1mg 1 daily
Timoptol Eye Drops 0.5% 1 drop each eye am & pm.
Normison 10mg as required

Non Prescription medications

Golden Glow Glucosamine Tablet – 1 with breakfast for arthritis

Vitamin C Complex Sustained Release – 1 with breakfast.

Mobility/ Aids

Independent with walking sticks. Arthritis in hands. Wears glasses.

Continence : Requires continence pad.

Recent Nursing Notes

16/05/09
Flu vaccination

29/06/09
Complaining of indigestion following evening meal. Settled with Mylanta.

07/07/09
Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison.

09/07/09
Requested Mylanta for indigestion, Panadol for shoulder pain – slept poorly.

10/07/09 am
Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit 11/07/09 after
surgery.

10/07/09 pm
Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of shoulder and neck
pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm
Rechecked 10.45pm – Distressed, pale and sweaty, comlaining of persistent chest pain, BP 190/100.
Ambulance called and patient transferred.

Writing Task
Write a letter for the admitting doctor of the Spirit Hospital Emergency Department. Give the recent
history of events and also the patient’s past medical history and condition.
Answer

10 /July/ 2009

The admitting Doctor

Emergency Department

Spirit Hospital

Dear Doctor,

Re: Ms Betty Olsen

DOB: 29 January, 1926

Ms Betty Olsen, a hypertensive client with persistent chest pain, is being transferred to your
care, as she requires immediate assessment and treatment at your provision.

Ms Olsen is a resident at Golden Pond Retirement village. She had tiredness and weakness today
morning and was confined to bed. At that time her blood pressure was 180/35mmhg. Later in
the evening, she refused meal as a result of nauseousness . She was also unable to sleep due to
shoulder and neck pain, which were treated with medications such as Nomison and Panadol.
Apart from the persistent chest pain , she was found to be pale and sweaty when she was
reassed at 10.45 pm. As her overall condition deteriorated, she is being referred to your facility
for an immediate admission.

In context of Ms Olsen past medical history, she has had hypothyroidism, hypertension and
glaucoma since 1997, 2003 and 2004 respectively. She is on regular medications for the same
.Importantly; she is allergic to pencillin and is on medications such as vitamin c and
glucosamine. She has athiritis in her hands. She also uses walking stick and wears glasses.

In this regard, you are requested to assess Ms Olsen condition and provide management as you
feel appropriate.

Thank you for accepting this referral. Should you require any clarifications, please do not
hesitate to contact me.

Yours sincerely,

Registered Nurse
WRITING TEST

Time: Reading – 5 minutes, Writing – 40 minutes

Read the case note below and complete the writing task which follows:

You are a nurse at Melbourne City Hospital.

Today’s Date : 3rd November, 2015

Personal Details : Jade Isow

D.O.B : 12th August, 2006

Date of admission : 2nd November, 2015

Date of Discharge : 3rd November, 2015

Social History : Lives with parents and younger brother in two bedroom house.

Medical History : No significant medical history

No known allergies to any drug or food item.

Reason of presenting : Fall onto an outstretched arm, pain, tenderness, bruising and swelling, wrist
hangs in an odd or bent way.

Diagnosis : Distal radius fracture

Treatment : X-rays of the wrist

Plaster cast applied
Analgesics and anti-inflammatory drugs : Ibuprofen and Acetaminophen to relieve pain and
inflammation.
Advice : Child may be sore for several days.
If child is in pain, please give painkillers as directed.
Please be sure not to overdose him nor he becomes addicted to the medicines.
May give painkillers regularly for the first 2-3 days as needed.

Child can go back to school as soon as he feels well enough.

X-ray after 3 weeks
Start Physiotherapy to help him improve the motion and function of the injured wrist.

Cast must be kept dry. A plastic bag over the arm while showering. If the cast does become
wet, it will not dry very easily.
A hair dryer on the cool setting may be helpful.

Child can resume light activities, such as swimming or exercising the lower body in the gym
 within 1 to 2 months after the cast is removed.
Vigorous activities, such as skiing or football, may be resumed between 3 and 6 months after
the injury.

Cast to be removed after about 6 weeks if no complication.

If you donot understand the advice provided, please speak to a member of the nursing staff or
doctors. If child suffers a lot of pain at home that does not get better with the painkillers,
please contact the doctor.

Writing Task

Write a letter of advice to Mr & Mrs Isow, 4/445 Hawlock St., Rokewood, Melbourne 3008 VIC
following discharge of their son, Samy, from the hospital.

In your answer

 Expand the relevant notes into complete sentences.

 Do not use note form.
 Use letter format.
Answer

03 November, 2015

Mrs and Mr Isow

4/445 Hawlock st

Rockwood

Melbourne 3008 VIC

Dear Mrs and Mr Isow,

Sub: Advice on your son’s care at home

As your son Jade Isow is being discharged home, I am briefing his current health status and the
care requires for your perusal.

During hospitalization, plaster cast was applied to him, as he had fracture to his forearm, which
was revealed on an x-ray. He was treated with medications such as ibuprofen and
acetaminophen to relieve pain and swelling. Jade recovers now and can go back to school as
soon as he feels well enough. Please note he may have pain for several days, for that painkillers
can be given as directed. However he should not be overdosed.

Though the child is able to do light activities within one to two months, vigorous activities such
as skiing or football can be resumed between three to six months. The applied cast must be kept
dry and you are requested to cover the site with plastic bag while showering. A hair dryer on the
cool setting may be helpful if it does become wet.

In view of above an x-ray is suggested after three weeks and his cast can be removed after six
weeks if there is no complications. It is important to initiate physiotherapy to improve the
motion and function of her injured wrist.

You are free to contact the nursing staff or doctors, if you need any clarification or assistance.

Yours sincerely,

Charge Nurse

Melbourne City Hospital

WRITING TEST

Time : Reading – 5 minutes , Writing – 40 minutes

Read the case notes below and complete the writing task which follows :

Information Letter

Notes :

You are a Community Nurse working in the Department of public Health and Awareness Camp , in
Melbourne ,Australia .

Background: Ebola is an infectious fatal disease marked by fever and severe internal bleeding spread
through contact with infected body fluids by a file virus (Ebola virus),whose normal host species is
unknown.

The spread of Ebola and its fatality has threatened Australian cities and the government has started
awareness campaigns for the forever safety of local people .

Ebola-case contacts:

Any person having been exposed to suspect ,probable or confirmed case of Ebola in at least one of the
following ways :

 Has slept in the same household with a case

 Has had direct physical contact with the case (alive or dead ) during the illness
 Has had direct physical contact with the (dead) case at the funeral
 Has touched his/her body or body fluids during the illness
 Has touched his/her cloths or lines
 Has been breastfed by the patient (baby)

Provided that this espouse has taken place less than 21 days before the identification as a contact by
surveillance teams .

Contact of dead or sick animals :

Person exposed to a sick or dead animal in at least one of the following ways :

Direct physical contact with the animal, expose to infected animal , contact with the animal’s blood or
body fluids ,eating raw fresh meat of stick animals.
Laboratory contacts :

Any person having been exposed to biological material in a laboratory in at least one of the following
ways :

 Has had direct contact with specimens collected from suspected Ebola patients .
 Has had direct contact with specimens collected from suspected Ebola animal cases

Provided that exposure has taken place less than 21 days before the identification as contact
surveillance teams.

Writing Task :

Using the information given above , write a letter to Mr .Martin John, Social Worker , Peace Way
Suburbs Health Clinic to conduct an awareness class for a group of Melbourne residents , many of whom
work in airline industry .

In your answer :

 Expand the relevant notes into complete sentences .

 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words

Answer

05/ July /2019

Mr Martin John

Social Worker

Peace Way Suburbs Health Clinic

Dear Mr Martin John,

Subject: To conduct an awareness class

Thank you for accepting the invitation to conduct an awareness class on the outbreak of Ebola
to a group of Melbourne residents.

As you are aware, the spread of Ebola has threatened Australian cities and the government has
started awareness campaigns. As Ebola is highly contagious and fatal disease, it is important for
Melbourne residents to know about its mode of transmissions and preventive measures. Ebola is
an infectious disease with the symptoms of fever and internal bleeding. It spreads through
contact with Ebola cases such as, contact with body fluids, direct physical contact or through
breast feeding by an infected mother

In addition, kindly educate on the other modes of transmission of Ebola such as contact with a
sick or dead animal or its body fluids, or consuming raw meat of sick animal. A person, who has
been exposed to biological materials such as, specimens collected from suspected patients or
animals, is also at risk of contracting the infection. Importantly, Ebola exposure takes place
within 21days of contact through suspected or confirmed cases.

If you have any queries, please contact me. Appreciating your effort to educate the residents.

Yours faithfully,

Community nurse

Public health and awareness camp

WRITING TEST

Time : Reading – 5 minutes , Writing – 40 minutes

Read the case notes below and complete the writing task which follows :

CASE NOTES

Name Mrs. Taylor Chapman

Age :38 years old

Family and social history

Marketing Manager ,married ,one child (four –year –old boy)

Medical history

Unremarkable ,no medications

11/07/05

Complaints of tiredness ,difficulty sleeping for 2 months due to work stress plans another child for 12
months ,currently on oral contraception pill (OCP)

P\E : Appears pale, tired and slightly restless.

Bp140\80 mmttg

Assessment:stress –related anxiety

Plan : advised relaxation techniques , reduce working hours ,prescribe sleeping tablets tds

15/08/06

Stopped OCP 4 months earlier .still menstruating

Worried

Sleep still difficult , stress unchanged ,not possible to reduce hours.

P/E:Tired –looking ,slightly restless

Assessment : work stress, growing anxiety failure to conceive

Plan : discussed nature of conception – takes time patience

Discussed frequency sexual intercourse

Discussed methods – temperature /cycle

18/01/07

Expressed anxiety re failure to conceive , says she’s too “old”

Sleep still problem

P/E:crying ,pale,fidgety

Vital signs / general exam NAD

Pelvic exam, Pap smear

Assessment : as per previous consultation

Improper prescription

Suggested she re- present next week accompanied by husband

25/01/07

Mr.Chapman very supportive of having another child

No erectile dysfunction, libido normal

Mr.Chapman normal

Plan : Check Mr. Chapman’s sperm count

02/02/07

Sperm count normal, Plan : Refer for specialist advice

WRITING TASK

Using the information in the case notes, write a letter of referral to Dr Lucy Clooney, a Gynecologist , at
123 Church St, Richmond 3121

In your answer :

 Expand the relevant notes into complete sentences

 Do not use note form
 User letter format

The body of the letter should be approximately 180-200 words

Answer

02 February, 2007

Dr Lucy Clooney

Gynecologist

123 Church st

Richmond 3121

Dear Dr Lucy Clooney,

Re: Mrs Taylor Chapman

Age: 38 years

Mrs Chapman, who is anxious about repeated failure to conceive a second child is being referred
to your care, as she requires further advice from you.

Mrs Chapman has a four- year old son and is planning to have another child. Mr Chapman’s
sperm count is normal as per the reports. It was noted that he has no erectile dysfunction and
has normal libido. However she failed to have a second pregnancy. She was pale, anxious and
complained about persisting sleeping problem, when she visited on 18 January 2007. Inaddition
pelvic examination and Pap smear was done at that time.

She was on oral pills, when she presented initially 2 years back on 11 July 2005, as they wish to
have their next baby after twelve months. She complained of tiredness and difficulty to sleep
due to work stress. On her second visit after one year, she was worried as she was still
menstruating, though she stopped the ocp four months earlier. Apart from the methods,
nature and frequency of conception also were discussed with her.

Your attention towards this case is greatly appreciated. Please feel to contact in case of any
queries.

Yours sincerely,

Charge Nurse
 Verb Tenses

Present Perfect
Present perfect tense is used to describe an event which starts in the past and continues until the present.
Mastery of this pattern is an essential for writing successful referral letters. Three common ways to form
present perfect when writing referral letters are as follows:

Present Perfect Simple Present Perfect Progressive Present Perfect Passive

Form : have/has + past participle
 I have treated Mr. Smith at
this hospital for 3 years.
 Dr. X has treated Mr. Smith
at this hospital for 3 years.
Form : have/has + been + ___ing
(Present Participle)
 I have been treating
Mr. Smith at this hospital for
3 years.
 Dr. X has been treating
Mr. Smith at this hospital for
3 years.
Form : have/has + been + past
participle
 Mr. Smith has been treated
at this hospital for 3 years
(..by Dr. X).
 They have been treated at
this hospital for 3 years(..by
Dr. X).

Present perfect is often combined with for/since/over. Compare the usage below and note
time markers used.
For Since Over
For is used to describe a period Since is used to refer to the start Over uses similar time markers
of time. of period of time. to for but is used to express a
change in condition, or to
 I have been treating the  I have been treating the describe a repeated event.
patient for 3 years. patient since 2007.
 The patient has been on this  The patient has been on this  The patient’s condition has
medication for 6 months. medication since January. deteriorated over the past 3
 I haven’t seen the patient for  I haven’t seen this patient months. (change in condition)
1 year. since December 2009.  The patient has presented
 The patient has been in pain  The patient has been in pain several times over the last
for 5 hours. since 10 am. year. (repeated event)
 The patient has been waiting  The patient has been waiting  The patient’s back pain has
for 15 minutes. since 11.45 am. worsened over the last
 He has been complaining of  He has been complaining of week. (change in condition)
back pain for a week. back pain since last week.  He has tried to quit smoking
 He has not had bowel  He has not had bowel several times over the past
motions for 3 days. motions since Saturday. 25 years. (repeated event)
 He has been a smoker for a  He has been a smoker since  The patient has experienced
period of 25 years. 1985. seizures on 3 occasions.
(repeated event)

 Handy Tip
When using time markers such as…. for the past 20 years, .... for the last 3 months, .... for the next 3 months or….
for the previous 3 months always use the definite article "the" as it its function is to specify a particular period
of time.
 Common Errors

Incorrect
 The patient was diagnosed hypothyroidism
since 2007.
Explanation: Past tense cannot be used with for or
since
 She has been problems with arthritis in her
hands.
Explanation : Problems in this sentence is a noun
so you can not use “been” with a noun. You must
use have or has + noun or been + ____ing verb.
You can also use been + adjective.
 He is smoking 2 packs of cigarettes a day for
the past 25-30 years.
 Over the past week she remains free from
severe pain and has been able to tolerate a
fluid diet.
 Also, there is an ulcer on the right lower lateral
border of the tongue which is present for
more than one year.
 Mr. Diamond is a patient of mine since 2000.
 Mr. Eddy is a known smoker for 25-30 years.
Explanation : The verbs in these sentences are in
simple present tense. Present perfect needs to be
used because you are referring to a time period
which started in the past and has continued to the
present.
 Mrs. Brown has been presenting to me on
several occasions over the past few months.
Explanation : Progressive form not required.
Correct
 The patient has had hypothyroidism since
2007. (Present Perfect)
 The patient was diagnosed with
hypothyroidism in 2007. (simple past)
 She has been having problems with arthritis in
her hands since 2007.(Present perfect
progressive)
 She has had problems with arthritis in her
hands since 2007. (present perfect simple)
 She has been arthritic since 2007. (present
perfect simple + adjective)
 She has had arthritis since 2007. (present
perfect simple + noun)
 He has been smoking two packs of cigarettes a
day for the past 25-30 years. .(Present perfect
progressive)
 Over the past week she has remained free
from severe pain and has been able to tolerate
a fluid diet. (Present perfect simple)
 Also, there is an ulcer on the right lower lateral
border of the tongue which has been present
for more than one year. (present perfect
passive)
 Mr. Diamond has been a patient of mine since
2000. (present perfect simple)
 Mr. Eddy has been a smoker for 25 years.
(present perfect simple)
 Mrs. Brown has presented to me on several
occasions over the past few months.

Simple Past or Present Perfect

There is often confusion of whether to use simple past or present perfect tense. The basic rule to remember is if
you are referring a particular time in the past then you must use simple past tense. If you are referring to a period of
time that starts in the past and continues up to now use present perfect tense.
There are some common time markers used with simple past and present perfect. It is important to study, learn
and use these tenses correctly when writing referral letters as you must refer to both past events and periods of
time leading to the present.
 Time Markers with Simple Past
 He sucked his thumb until he was 5.
 Mrs. Kelly had diverticulitis when she was a
teenager.
 He first came to see me in 2004.
 The patient didn’t respond to treatment.
 The patient was diagnosed with cancer 3
months ago.
 The patient stopped taking medication
yesterday.
Time Markers with Present Perfect
 He has been sucking his thumb for five
years.
 Mrs. Kelly has had diverticulitis for the last
12 years.
 He has been seeing me since 2004.
 The patient hasn’t responded to treatment
yet.
 The patient has shown no signs of
improvement up to now.
 The patient has stopped taking medication
recently.

Common Errors
Incorrect Correct
 She has underwent triple coronary bypass  She underwent triple coronary bypass surgery
surgery on 10.08.09 on 10.08.09

Active and Passive Verb Formation

In writing a referral letter it is necessary to use a variety of verb forms including both active and passive verb.
Using active verbs is good when you wish to create a personal tone or impart subjective information. However
passive verbs and sentence structures enables the writer to be more objective and focus attention on what is
most important in a sentence such as the patient, procedures and treatment rather than on themselves.

Compare
1. I advised the patient to stop smoking.
2. The was advised to stop smoking (focus on the patient)

1. I advised her to do bed exercises to prevent further complications such as deep vein thrombosis.
2. Bed exercises were advised to prevent further complications such as deep vein thrombosis. (focus on
the treatment)

1. You need to take Flucloxacillin capsules twice a day for a duration of 2 weeks.
2. Flucloxacillin capsules need to be taken twice a day for a duration of 2 weeks. (focus on the
medication)

To form the passive, use the be verb (be, is/ are; was/were; has been/have been) + past participle as described in
the table below.

Active Passive
Present Simple Present Simple
 The patient takes aspirin daily.  Aspirin is taken daily.
Present simple continuous Present simple continuous
 The patient is taking aspirin daily.  Aspirin is being taken daily.
Past simple Past simple
 The patient took aspirin daily.  Aspirin was taken daily.
 The patient took 3 tablets daily.  3 tablets were taken daily.
Past simple continuous
 The patient was taking aspirin daily.
Present perfect
 The patient has taken aspirin daily for a period
of one year.
 The patient has taken aspirin, noten and
normison for a period of one year.
Present perfect continuous
 The patient has been taking aspirin daily.
Past perfect
 The patient had taken aspirin daily for a period
of one year.
 The patient had taken aspirin, noten and
normison for a period of one year.
Past perfect continuous
 The patient had been taking aspirin daily.
Future
 The patient will take aspirin in the evening
Modal form
 The patient should have taken aspirin in the
evening.
Please review the list of common mistakes below.
Incorrect
 She was performed a colostomy accompanied
with a partial bowel resection.
 As per the doctor’s order, we were organized
daily home visits.
 On 9.7.06 he was presented to me for his
regular check up.
 On the subsequent visit the treatment options
was discussed.
Past simple continuous
 Aspirin was being taken daily.
Present perfect
 Aspirin has been taken daily for a period of
one year.
 Aspirin, noten and normison have been taken
for a period of one year.
Present perfect continuous
 Nil : This form is rarely used in the passive..
Past perfect
 Aspirin had been taken daily for a period of
one year.
 Aspirin, noten and normison had been taken
for a period of one year.
Past perfect continuous
 Nil : This form is rarely used in the passive.
Future
Aspirin will be taken in the evening
Modal form
Aspirin should have been taken in the evening.
Correct
 A colostomy was performed with a partial
bowel resection.
 A colostomy was performed on the patient by
the doctor with a partial bowel resection.
The first example is better as it more concise and also it is
obvious the roles of patient and doctor so it is
unnecessary to state them.
 As per the doctor’s order, daily home
visits were organized. (passive)
 As per the doctor’s order, we organised
daily home visits. (active)
Both sentences are grammatically correct but the first
example is preferred because it focuses attention on the
procedure.
 On 9.7.06 he presented to me for his
regular check up. (active)
Active voice is preferred here as the patient is the
subject and most likely presented himself.
 On the subsequent visit the treatment
options were discussed.
Because the noun is plural the plural verb “were” is

 She had done colonoscopy 3 years ago.
 Initially, she came to me on 14/01/2006 for a
general check up and was found her blood
pressure 160/90.
 In addition, her baby will need to monitor his
growth and general health condition.
 Noten 50mg 1/2 tablet daily was prescribed
while Zocor and Calcium Caltrate were
continued taking.
 Today at my surgery attended Mr. Attard
complaining of pain in his upper left molar.
required.
 A colonoscopy was done 3 years ago.
 She had a colonoscopy done 3 years ago.
In these sentences it is unimportant who performed the
colonoscopy so passive voice is used.
 Initially, she came to me on 14/01/2006 for a
general check up and her blood pressure was
found to be 160/90.
After the conjunction and a subject is required.
 In addition, the baby’s growth and general
health condition will need to be monitored.
Future form of the passive.
 Noten 50mg 1/2 tablet daily was prescribed
while Zocor and Calcium Caltrate were
continued to be taken.
 Today, Mr. Attard attended surgery
complaining of pain in his upper left molar.
Use active form here as you need to focus on your
patient, not your surgery.

Past Perfect

Past perfect is an important tense in referral letters. The main functions of this tense are:

 When used with simple past it allows the writer to distinguish the order of events :

o She had not been able to conceive over the previous four months and as a result she was suffering from
depression. This means: first she could not conceive, then she became depressed.

 When used in reported speech. The case notes may describe the patient's condition at a time in the
past, i.e patient found blood in towel 2 times. This can be written in the referral letter as follows:

o At today’s consultation, Ms. Leon reported that there had been blood in the toilet bowl on 2 occasions.

So the main benefit of using past perfect is that it allows the writer to express the order in which certain health
events occurred logically and clearly.

 Handy Hint 1
Do not use past perfect when describing one past event as it is not necessary.

Compare
 The patient had been feeling unwell last week.(incorrect if 1 past event described)
 The patient was feeling unwell last week. (correct)
 The patient had been feeling unwell last week and was admitted to hospital for observation. (correct as 2 past
events need to be distinguished)
 Handy Hint 2

Past perfect is often used with the word previous instead of ago to demonstrate that you are referring to a time
before a particular date in the past, not the date you are writing the letter. See below for examples.

Incorrect Correct
 She presented to me on 03/07/2010 for a  She presented to me on 03/07/2010 for a
regular check up because she experienced regular check up because she had experienced
several episode of heart flutter over the past several episodes of heart flutter over the
few weeks. previous few weeks.
o Past perfect tense is necessary here (had
experienced) to differentiate what happened
prior to the check up, which is also in the past.
o As your meaning is prior to 03/07/10 and not the
day of writing the letter, you should use the
word previous instead of past.
 On review two weeks later, the frequency of  On review two weeks later, the frequency of
headache decreased. headache had decreased.
o Use past perfect to indicate that frequency of
headache had decreased prior to the
consultation.
 A review on 25/04/10 showed the patient’s  A review on 25/04/10 showed the patient’s
general health improved and her blood general health had improved and her blood
pressure dropped to 140/85 and she lost 4 kg. pressure had dropped to 140/85 and she had
o Past perfect is used when describing a lost 4kg.
condition that was true at a certain time in the
past.
 She presented to me yesterday evening with  She presented to me yesterday evening with
abdominal pain, mostly on the left iliac fossa, abdominal pain, mostly on the left iliac fossa,
and was since 24 hours. which had been occurring for the previous 24
1. Note that in the correct version 3 different hours.
times need to be considered
2. The present i. e today: time of writing
3. Yesterday evenings consultation
4. Symptoms which occurred before yesterday's
consultation
 She was admitted in Royal Brisbane and  She was admitted in Royal Brisbane and
Women’s Hospital on 24/07/08 because she Women’s Hospital on 24/07/08 because she
collapsed at home. had collapsed at home.
o Use past perfect tense to create a time line, so
past perfect indicates the collapse occurred
before the admission.
 Initially she presented to me in July 2010 with  Initially she presented to me in July 2010 with
a complaint of chest discomfort for three a complaint of chest discomfort which had
weeks. been present for three weeks.
o If you use this time expression: for a few weeks  Initially she presented to me in July 2006 with
then you must either use a relative clause and a complaint of chest discomfort of 3 week
past perfect verb tense, or the very concise and duration.
useful expression: of duration.
 Mrs. Jones had taken Microgynon 30 for the  Mrs. Jones had taken Microgynon 30 for the
previous 5 years but had stopped in May 2009. previous 5 years but stopped in May 2009.
o There is no need to use past perfect twice.
 On rechecking at 10.45pm, her condition has  On rechecking at 10.45pm, her condition had
 further deteriorated and an ambulance was further deteriorated and an ambulance was
arranged for transfer to hospital. arranged for transfer to hospital.
o Use past perfect and simple past together to
distinguish the order of events i.e, her condition
deteriorated then an ambulance was called.

Making Subjects and Verbs Agree

This handout gives you several guidelines to help your subjects and verbs agree.

1. When the subject of a sentence is composed of two or more nouns or pronouns connected by and, use a plural
verb.

She and her friends are at the fair.

2. When two or more singular nouns or pronouns are connected by or or nor use a singular verb.

The book or the pen is in the drawer.

3. When a compound subject contains both a singular and a plural noun or pronoun joined by or or nor, the verb
should agree with the part of the subject that is nearer the verb.

The boy or his friends run every day.

His friends or the boy runs every day.

4. Doesn't is a contraction of does not and should be used only with a singular subject. Don’t is a contraction of do
not and should be used only with a plural subject. The exception to this rule appears in the case of the first person
and second person pronouns I and you. With these pronouns, the contraction don't should be used.

He doesn't like it.

They don't like it.

5. Do not be misled by a phrase that comes between the subject and the verb. The verb agrees with

One of the boxes is open

The people who listen to that music are few.

The team captain, as well as his players, is anxious.

The book, including all the chapters in the first section, is boring.

The woman with all the dogs walks down my street.

6. The words each, each one, either, neither, everyone, everybody, anybody, anyone, nobody, somebody,
someone, and no one are singular and require a singular verb.
Each of these hot dogs is juicy. each anybody everybody
eachone anybody everybody SINGULAR
Everybody knows Mr. Jones.
either no one somebody
Either is correct. neither nobody someone
7. Nouns such as civics, mathematics, dollars, measles, and news require singular verbs.

The news is on at six.

Note: The word dollars is a special case. When talking about an amount of money, it requires a singular verb, but
when referring to the dollars themselves, a plural verb is required.

Five dollars is a lot of money.

Dollars are often used instead of rubles in Russia.

8. Nouns such as scissors, tweezers, trousers, and shears require plural verbs. (There are two parts to these
things.)

These scissors are dull.

Those trousers are made of wool.

9. In sentences beginning with there is or there are, the subject follows the verb. Since there is not the subject,
the verb agrees with what follows.

There are many questions.

There is a question.

10. Collective nouns are words that imply more than one person but that are considered singular and take a singular
verb, such as group, team, committee, class, and family.

The team runs during practice.

The committee decides how to proceed.

The family has a long history.

My family has never been able to agree.

In some cases in American English, a sentence may call for the use of a plural verb when using a collective noun.

The crew are preparing to dock the ship.

In some cases in American English, a sentence may call for the use of a plural verb when using a collective noun.

The crew are preparing to dock the ship.

This sentence is referring to the individual efforts of each crew member. The Gregg Reference Manual provides
excellent explanations of subject-verb agreement (section 10: 1001).
11. Expressions such as with, together with, including, accompanied by, in addition to, or as well do not change the
number of the subject. If the subject is singular, the verb is too.

The President, accompanied by his wife, is traveling to India.

All of the books, including yours, are in that box.

When the subject follows the verb

When the subject follows the verb (especially in sentences beginning with the expletives "there is" or "there
are"), special care is needed to determine the subject and to make certain that the verb agrees with it.

On the wall were several posters.

There are many possible candidates.

There is only one good candidate.

When words like "each" are the subject

When used as subjects, words such as

 Each, either, neither

 another
 anyone, anybody, anything
 someone, somebody, something
 one, everyone
 everybody, everything
 no one, nobody, nothing

take singular verbs.

Do not be confused by prepositional phrases which come between a subject and its verb. They do not change
the number of the subject.

Each takes her turn at rowing.

Neither likes the friends of the other.

Everyone in the fraternity has his own set of prejudices.

Each of the rowers takes her turn at rowing.

Every one of the fraternity members has his own set of prejudices.
 When words like "none" are the subject
Other words such as

 none, any, all

 more, most, some

may take either singular or plural verbs, depending on the context.

Some of the dollar was spent.

Some of the dollars were spent.

[Note: here the prepositional phrase does affect the subject. It tells you whether you are talking about a part of
one thing (singular) or about a number of things (plural).]

When the subjects are joined by "and"

Subjects joined by "and" take plural verbs.

Be aware: phrases such as "in addition to,“ “as well as, “and” along with” do not mean the same thing as "and."
When inserted between the subject and the verb, these phrases do not change the number of the subject.

Both Tom and Jane have English 167 papers due on Tuesday.

Tom, as well as Jane, has an English 207 paper due Tuesday

When singular subjects are joined by words like "or"

Singular subjects joined by "or," "nor," "either... or," or "neither... nor" take a singular verb.

Either the man or his wife knows the truth of the matter.

Neither money nor power was important any longer.

When one subject is singular and one plural

If one subject is singular and one is plural, the verb agrees with the nearer subject.

Neither the television nor the radios work.

Neither the radios nor the television works.

 When a linking verb is used
A linking verb “is,“ “are,” “was,” “were,” “seem” and others agrees with its subject, not its complement.

Joe's favorite dessert is blueberry muffins.

Blueberry muffins are Joe's favorite dessert.

When a collective noun is used

When regarded as a unit, collective nouns, as well as noun phrases denoting quantity, take singular verbs.

The whole family is active.

(Family is a collective noun regarded as a unit.)

The family have met their various obligations.

(The individuals of the family are regarded separately.)

A thousand bushels is a good yield.

(a quantity or unit)

A thousand bushels were crated.

(individual bushels)

When a relative pronoun is used as a subject of an adjective clause

A relative pronoun ("who," "which," or "that") used as a subject of an adjective clause takes either a singular or
plural verb in order to agree with its antecedent.

A vegetable that contains DDT can be harmful.

(Adjective clause modifying the singular noun "vegetable.")

Vegetables that contains DDT can be harmful.

 (Adjective clause modifying the plural noun "vegetables.")

Mary is one of the students who have done honor to the college.

(Adjective clause modifies the plural noun "students." "Students" is the antecedent of "who."

In the above sentence Mary is just one of the students. So at least two students have done honor to the
college.

Compare that to: singular

Mary is the only one of our students who has achieved national recognition.

In this case, "one," not "students," is the antecedent of "who."

Compare the sentences above:

Of all our students, Mary is the only one who has achieved national recognition.
 Article Usage

Articles Usage with Countable & Uncountable Nouns

Whether an article is required or not depends on the noun that follows. For this purpose nouns can be classified
into two types: countable & uncountable nouns. The difference is based on whether the noun can be counted or
not. For example complaint is a countable noun as it can be counted. Therefore it is possible to say 1 complaint or
2 complaints. Advice on the other hand
cannot be counted so it is not possible to say 1 advice or 2 advices , The correct expression is some/any advice
or the expression a piece of advice.

Countable nouns
These nouns have a singular form and plural form.

Singular
In the singular form an article is usually used before the noun. Example: The doctor received a complaint from
her patient.
NB. Exceptions: The article can be left out if it is replaced with another determiner such as his/her or this /that or
any/each/every. E.g. The doctor listened to each complaint. Her complaint was recorded.

Plural
In the plural form the article is usually not used before the noun. Example: The doctor received complaints from
her patients.

Remember: Always use articles when referring a particular job such as:
doctor/dentist/nurse/pharmacist/physiotherapist/teacher etc etc.

Countable nouns Singular form Plural form

Note the use of an article before Note the absence of the indefinite a/an before
each noun in singular form, each noun in singular form, but the definite
either as a/an/the article.
abscess The patient had an abscess The patient had 3 abscesses on her gum.
on her gum.
ache The patient reported a dull The patient suffered from aches and pains.
ache in her abdomen.
accountant Mr. Hagen is an accountant. Mr. & Mrs. Hagen are both accountants.
appointment A follow-up appointment was The patient did not attend her follow-up
scheduled. appointments.
cavity The cavity was exposed. The cavities were exposed.
check up The patient attended for a Regular check-ups will keep you healthy.
check-up.
complaint If you have a complaint, tell If you have any complaints, tell your doctor.
your doctor.
condition You have a condition known There are 3 conditions which can indicate
as tuberculosis. the presence of cancer.
deposit A carious deposit was evident Carious deposits were evident on teeth 32 &
on tooth 32. 33.
doctor The patient has not seen a Three doctors were involved in the
doctor for several years. treatment of the patient.
 episode The patient had an episode of The patient reported 3 episodes of heart
heart flutter. flutter.
examination An examination is necessary to Blood urine examinations revealed no
rule out cancer. abnormalities.
gum The gum surrounding tooth The gums were infected.
23 was inflamed.
increase There was an increase in The patient presented with numerous
the size of the swelling. swellings.
interpreter An interpreter is required. Interpreters will be required.
investigation An investigation is required to Investigations are required to rule out bowel
rule out bowel cancer. cancer.
limp The patient walked with a All the patients had limps.
limp.
parasite The threadworm is a parasite. Threadworms are parasites.
lip The patient had a swollen lip. The patient had swollen lips. (both lips)
(one lip)
smoker She is a smoker. They are smokers.
operation An operation is necessary. Two operations are necessary.
painkiller The patient requested a Painkillers are not necessary with this
painkiller. procedure
physiotherapist An appointment needs to Two physiotherapists work at this
be a arranged with a rehabilitation centre.
physiotherapist.
result The patient hoped for a The results were positive.
positive result.
review A review was scheduled after The nurse received positive reviews from her
2 weeks. patients.
sensation The patient reported a tingling The patient experience tingling sensations in
sensation in his fingers. his fingers.
social worker A social worker has been Two social workers have been arranged to
arranged to offer ongoing offer ongoing care.
care.
teacher Steve is a teacher. Steve and Chris are teachers.
test A blood test was ordered. Blood and urine tests were ordered.
visit Please organise a visit by a Regular visits by a social worker are
social worker. required.

Uncountable nouns
These nouns cannot take a plural form such as: cancer, anesthesia and information. For these words no article is
required. However, the definite article the as well as quantifiers such as some and any can be used before the
noun.

Uncountable nouns Indefinite articles cannot be used with

uncountable nouns. However definite
article “the” as well as quantifiers such as
some and any can be used.
accommodation The patient lives in rental accommodation.
advice Advice on diet is requested.
assistance The patient will require assistance upon discharge.
attention The patient requires urgent attention.
 behaviour On examination, the patient's behaviour was
abnormal.
cancer The patient has cancer.
caries Deep caries were present on several teeth.
concentration The patient has poor concentration.
damage The scan confirmed damage to the medial
cartilage.
discomfort If you experience discomfort, please consult your
doctor.
information Should you require further information, please
do not hesitate to contact me.
pain The patient experienced pain on palpation.
progress The patient has made good progress.
tissue She has healthy, soft tissue.
treatment The condition did not respond to treatment.
research Further research is required.
surgery The patient chose not to have surgery.

Common mistakes
Incorrect Correct
Wound on her left knee has been stitched. A wound on her left hand has been stitched.

I am writing to refer Marvin, 7 year old boy who I am writing to refer Marvin, a 7 year old boy
was admitted to hospital on 21/11/10. who was admitted to hospital on 21/11/09.

Mr Brown has been patient of mine for 7 years. Mr Brown has been a patient of mine for 7 years.

Please note, the patient has had prosthetic heart Please note, the patient has had a prosthetic
valve for year. heart valve for a year.

Examination revealed abscess on her gum. Examination revealed an abscess on her gum.

Apart from bruises to her body, X-rays reveal Apart from bruises to her body, X-rays reveal
that she has fracture of the right ankle. that she has a fracture of the right ankle.

Mr Jones had a heart surgery in 2009. Mr Jones had heart surgery in 2009.

The patient has a cancer. The patient has cancer.

She had a healthy soft tissue. She had healthy soft tissue.

He had lacerated lip and swollen gum. He had a lacerated lip and swollen gums.

The patient has pollen allergy. The patient has a pollen allergy.

The patient has tender right elbow joint. The patient has a tender right elbow joint.

The patient presented for regular check-up on The patient presented for a regular check-up on
12/2/10. 12/2/10.
 New Information Vs Previously Mentioned Information
Indefinite Article: A or An
When you mention something for the first time the indefinite article a/an is required. This signifies to the
reader that it hasn’t been mentioned before.
Definite Article: The
When you mention something for the second and subsequent times that we mention it the definite article the
is required because we are referring a something which has been mentioned before.
Example: Initially, she came to me on 03/07/06 for a blood test. The results of the blood test were negative.

Correct application of this rule creates cohesion in your letter as you are able to connect ideas, as in the
example above, where the reader knows which blood test is being referred. Conversely, incorrect use can
confuse the reader.

Example: Initially, she came to me on 03/07/06 for the blood test. The results of a blood test were negative.

In the example above the ideas are not connected and the reader will be confused.

Incorrect Correct
 The patient has the family history of diabetes.  The patient has a family hist+ory of diabetes.

Explanation: If it is the first time to give this

information then the indefinite article is required for
countable nouns.

 In addition, the pain in the right
knee joint has appeared over the
last 2 days.
 Thank you for seeing, Mr and Mrs
Conway, who have presented to me for
fertility advice.
 In addition, pain in the right knee joint
has appeared over the last 2 days.
 Thank you for seeing, Mr and Mrs
Conway, who have presented to me for
fertility advice.

Explanation: If it is the first time to give this

information and the word is an uncountable noun,
such as pain or advice, then no article is required.
Note, this error has a big effect on meaning: the in
this case implies that this subject has been
mentioned previously, which of course it hasn't.
For more details on countable & uncountable nouns
click here

 Thank you for seeing this patient, an eight
year old girl who presented today with the
broken left arm following the accident at his
school play ground. It has been forty minutes
since accident.
 Thank you for seeing this patient ,an eight
year old girl who presented today with a
broken left arm following an accident at his
school play ground.It has been forty minutes
since the accident.
 Referring to Something Specific

The definite article is used when referring to something specific. It is very important to include this article to
signify the information is specific.

Note: These articles are usually omitted in the case notes. This is because the case notes are in short note form
and standard grammar rules do not apply. However for referral letters it is necessary to apply and adhere to
standard grammar rules.

Incorrect
 She was on Microgynon 30 for previous 5 years.
 He has been a smoker for last 12 years.
 Mr. Roberts has been a resident at our nursing
home for past 2 years.
 This medication needs to be taken twice a
day for next 3 days.
Explanation: All the expressions above are
referring to a specific period of time so a definite
article is required.
Correct
 She was on Microgynon 30 for the previous 5
years
 He has been a smoker for the last 12 years.
 Mr. Roberts has been a resident at our nursing
home for the past 2 years.
 This medication needs to be taken twice a day
for the next 3 days.

 Mrs Sangean is currently on following  Mrs Sangean is currently on the following

medication: karvea 150mg daily, oroxinen 0.1 medication: karvea 150mg daily, oroxinen 0.1
daily. daily

Explanation:In this case, the writer is referring to

specific medication. i.e that which follows.

 The patient reported pain in left ankle.  The patient reported pain in the left ankle.

Explanation: Here the writer is referring to a

specific side, i.e not the right side but the left
side.

 Patient complained of chest pain.  The patient complained of chest pain.

Explanation: Patient requires an article to

indicate which patient the writer is referring to.

 Examination revealed a slightly swollen joint  Examination revealed a slightly swollen joint
and a tender spot on medial aspect of it. and a tender spot on the medial aspect of it.

Explanation: Here the writer is referring to a

specific region,
i.e not the anterior aspect but the medial aspect.
 Based on above information, I believe the  Based on the above information, I believe the
patient needs urgent admission to hospital. patient needs urgent admission to hospital.

Explanation: Here the writer is referring to a

specific information, i.e not the information on
the medical chart but the information written
above.

 Thank you for seeing this patient who  Thank you for seeing this patient who
presented at my surgery regarding tooth 54 presented at my surgery regarding tooth 54
which has been temporary filled by school which has been temporary filled by the
dental service. school dental service.

Explanation: Here the writer is referring to a

specific dental service, i.e not the community
dental service but the school dental service.
 Special Usage of Articles
There are some situations where you should always use the definite article and there are some situations where
the indefinite article is required. Understanding these rules can greatly reduce the number of "minor" errors in
your writing so please study these rules carefully.

Handy Hint!
Articles are usually omitted in the case notes. This is because the case notes are in short note form and standard
grammar rules do not apply. However for referral letters it is necessary to apply and adhere to standard
grammar rules including article usage.

Body Parts

The definite article "the" should be used when referring to parts of the body.

Incorrect Incorrect
 Pain in left groin.  Pain in the left groin.
 Pain in stomach.  Pain in the stomach.
 I suspect it to be adenoma of parotid gland.  I suspect it to be adenoma of the parotid gland.
 Mr. Smith had an operation on a left knee.  Mr. Smith had an operation on the left knee.

Names of Diseases
Do not use an article for names of diseases or conditions.

Incorrect
 The patient is suffering from the high blood
pressure.
 Recently, the patient has complained of the
headache.
 The patient was diagnosed with the arthritis.
 The patient has had the influenza for three days.
Correct
 The patient is suffering from high blood
pressure.
 Recently, the patient has complained of
headache.
 The patient was diagnosed with arthritis.
 The patient has had influenza for three days.

Same
Always use the definite article with this word.

Incorrect
 She has a family history of same disease
that had been controlled by Risperidone.
 The children were treated by same dentist.
 The medication is same as last time.
Correct
 She has a family history of the same
disease that had been controlled by
Risperidone.
 The children were treated by the same
dentist.
 The medication is the same as last time.

Articles with Gerunds

A gerund is the …ing form of a verb which takes on the grammatical function of a noun. It can be the subject or
object in a sentence. Usually no article is required with gerunds.
 Incorrect
 On review today, Mr Walker has
reduced the smoking from 20 to 10
cigarettes per day.
 The patient was advised to stop the drinking.
Correct
 On review today, Mr Walker has reduced
smoking from 20 to 10 cigarettes per day.
 The patient was advised to stop drinking.

Articles and Nominalisation

Nominalisation is a process where verbs can be turned into a "noun phrase". For example:The patient sucked
his thumb until he was five becomes The patient had a habit of thumb sucking until the age of five.

Often in medical English, it is necessary to use nominalisation such as: The excessive drinking of alcohol will
adversely affect your health. The reduction of weight has led to improved health. It is common in these cases to
use an article before the nominalised expression.
The other benefit of using the style of writing is that it creates a formal tone and allows you to summarise
details from the case notes.

Incorrect Correct
 The patient is complaining of discomfort  The patient is complaining of discomfort
during passing of urine. during the passing of urine.

Appropriateness of Language
Informal & Casual Expressions
The written language of English is different to the spoken language in that it is quite formal whereas the spoken
form is more casual. If spoken language expressions are used in formal letters it affects the “tone and register”
of the letter. Therefore, it is important to maintain a formal tone and use standard expressions. Below is a list of
inappropriate casual expressions with more formal appropriate expressions.

Example Words

Casual Formal Casual Formal Casual Formal Casual Formal Casual Formal Casual Formal
asks for requests think believe get became so very but however kids children
say state get receive got become about regarding really greatly sad depressed
said stated got received So Therefore a bit slightly kid child till until
like include like such as don't do not Thanks Thank- kids children lots a lot of
you

Example Sentences

Inappropriate Casual or Spoken Appropriate Formal Expression

Expression
 She refuses to eat solids and prefers fluids
only like apple juice and lemonade.
 There are several measures which can be
taken to reduce the risk of infection like
taking a shower in morning, using separate
towel for everyone, changing underwear and
bed sheets regularly, vacuuming carpets,
keeping the nails short and washing hand
thoroughly.
 She was given general advise for softening her
stool,like changing her dietary habit but she was
non compliant.
Explanation: Like is a casual expression, and the
two commonly used formal expressions with the
same meaning are such as & including.
 Thanks for seeing Mr. Brown.
 Thanks for arranging a home visit for this
patient. If you have any further questions,
please feel free to ask me.
Explanation: Thanks is a casual expression and
should be written in full.
 In view of the above signs and symptoms I
think she is suffering from schizophrenia.
 The patient's family is thinking about a
reduction in her medication.
Explanation: think is informal and preferable
expression is either believe or consider,
depending on the context.
 I would really appreciate your attention
regarding further management of this
patient.
Explanation: Really is spoken language and
should be avoided in formal writing.
 About his dietary habits, he eats a large
amount of oily and sweet food.
 If you require any other information about
her condition, please do not hesitate to
contact me.
Explanation: About is a casual expression,
regarding is more suitable. Lots of is also casual.
“A large amount of” is more formal.
 She refuses to eat solids and prefers fluids
such as apple juice and lemonade.
 There are several measures which can be taken
to reduce the risk of infection including taking a
shower in morning, using separate towel for
everyone, changing underwear and bed sheets
regularly, vacuuming carpets, keeping the nails
short and washing hand thoroughly.
 She was given her general advise for softening
her stool such as changing her dietary habit but
she was non compliant.
 Thank you for seeing Mr. Brown.
 Thank you for arranging a home visit for this
patient. If you have any further questions,
please be free to ask me.
 In view of the above signs and symptoms I
believe she is suffering from schizophrenia
 The patient's family is considering a reduction
in her medication.
 I would very much appreciate your
attention regarding further management
of this patient.
 I would greatly appreciate your attention
regarding further management of this patient.
 Regarding his dietary habits, he eats a large
amount of oily and sweet food.
 If you require any other information
regarding her condition, please do not
hesitate to contact me.
  She had lots of pain.
 He eats lots of oily food.
Explanation:Lots is a spoken expression
 There was nothing significant in his social history.
Explanation: Nothing is more commonly a
spoken expression which is not suitable for
writing.
 Please do not hesitate to contact me if u
need additional information.
Explanation: Definitely no text or SMS language in formal
letters. Replace with: you
 She has got maternal postpartum
haemorrhage of 800mls.
 Mr O’ Riley got an appointment for a follow up
visit with his general practitioner, Dr. Avril
Jensen.
 The mother got sick for a few days.
Explanation: Got/Get are casual expressions and
should generally be avoided in formal letters.
 Should you have any concerns regarding
them, please do not hesitate to contact
me.
Explanation: The pronoun them sounds casual
here. It is much better to use the patient’s name,
especially in the final sentence of the letter.
 At the moment, she is weak and
disorientated sometimes but severe pain
has been alleviated.
Explanation: Sometimes is a casual expression.
More formal expressions include: at times or on
occasions
 This pain was exaggerated to cold and hot things
Explanation: Things is a casual expression and
should be avoided
 A repeat vaginal examination revealed a very
tender right vaginal fornix. But her blood
pressure pulse is within normal range.
Explanation: It is not good English to begin a
sentence with the conjunction but In this case
 She had a lot of pain.
 He eats large amounts of oily food.
 There were no significant findings in his
social history.
 Please do not hesitate to contact me if you
need additional information.
 She has had maternal postpartum
haemorrhage of 800mls.
 Mr O’ Riley has an appointment for a follow up
visit with his general practitioner, Dr. Avril
Jensen.
 The mother became sick for a few days
 Should you have any concerns regarding Mary
and her child, please do not hesitate to
contact me.
 At the moment, she is weak and
disorientated at times but severe pain has
been alleviated.
 9.At the moment, she is weak and
disorientated on occasions but severe pain has
been alleviated.
 This pain was exaggerated to hot and cold
stimuli.
 A repeat vaginal examination revealed a very
tender right vaginal fornix. However, her blood
pressure pulse is within normal range.
 use However, as it is more formal
 Her temperature and blood pressure were
normal while pulse was elevated at 88. So I
recommended that she return today for a
blood test and reassessment.
Explanation: So is a casual word, you can use it
within a sentence, but not to start a sentence in
formal writing. Replace with: Therefore,
 There was evidence of poor oral hygiene,
carious lesions and active periodontal
disease too.
Explanation: too is informal, a more more formal
expression is as well.
 Her husband was upset because, she was not
showing interest towards the kids.
 Mark's dad also suffers from this condition.
 The teacher spoke to her mum regarding the
regular absences from school.
Explanation: kids, dad, mum are all spoken
expressions which are inappropriate in formal
letters.
 She had had termination of pregnancy 10 years
back.
 He is a regular smoker and drinker with the
only relevant past history of left inguinal hernia
operation 2 years back.
Explanation: Back is used as a spoken expression
not a written expression.
 He had a habit of thumb sucking till
the age of 5.
Explanation: Till is casual, until is formal
 She was so anxious.
Explanation: So is informal and subjective,
whereas very is more formal and objective.
 Owen has big tonsils.
 Her temperature and blood pressure were
normal while pulse was elevated at 88.
Therefore, I recommended that she return
today for a blood test and reassessment.
 There was evidence of poor oral hygiene,
carious lesions and active periodontal
disease as well.
 Her husband was upset because, she was not
showing interest towards the children.
 Mark's father also suffers from this condition.
 The teacher spoke to her mother regarding the
regular absences from school.
 She had had termination of pregnancy 10 years
ago.
 He is a regular smoker and drinker with the
only relevant past history of left inguinal hernia
operation 2 years previously.
 He had a habit of thumb sucking until the age of
5.
 She was very anxious.
 Owen has enlarged tonsils
 Explanation: big is informal and does not sound
professional.
 I am writing to request a follow-up for this
patient.
 Examination revealed that his vitals were
stable and left knee was swollen without
effusion.
 Examination revealed normal vitals.
Explanation: Vitals and follow up are incomplete
expressions, commonly used in spoken English,
but not suitable for formal writing.
 Mrs. Jones is a widow who complained of
persistent chest pain at roughly 1.45pm.
 Miss Roberts started smoking around 6 months
ago.
Roughly and around are casual or vague
expressions.
 I recommend some investigations to rule out
cancer.
 I requested some blood tests.
Explanation: Some is vague and does not sound
professional.
 Her BMI was 28 and all the rest of the
examinations were normal.
Explanation: all the rest of sounds informal.
 Abdominal examination revealed a small right
groin swelling that’s consistent with inguinal
hernia.
 Thank you for your expert care and please
don't hesitate to contact us if you require
further information.
Explanation: It is best to avoid contractions in
formal letters as these are used more in spoken
English.
 In addition, she is just able to tolerate fluids.
Explanation:Just can sound informal at times.
 I am writing to request a follow-up visit for
this patient.
 Examination revealed that his vital signs were
stable and left knee was swollen without
effusion.
 Examination revealed that his vital signs were
normal.
 Mrs. Jones is a widow who complained of
persistent chest pain at approximately 1.45pm.
 Miss Roberts started smoking
approximately 6 months ago.
 I recommend further investigations to rule out
cancer.
 I requested additional blood tests.
 Her BMI was 28 and the remainder of
the examinations were normal.
 Abdominal examination revealed a small right
groin swelling that is consistent with inguinal
hernia.
 Thank you for your expert care and please
do not hesitate to contact us if you require
further information.
 In addition, she is only able to tolerate fluids.
 Medical Terminology
The medical case notes for the OET exam often contain abbreviations, medical acronyms and technical
language. The task for the writer is to expand these into full words and sentences. There are 3 reasons why this
is important.

1. As the OET is a test of English, you need to demonstrate your ability to transfer technical language in
the case notes into standard English.
2. For some letters you are may have to write to someone who is not a health professional such as a
social worker or family member.
3. A referral letter is not a report so the standard conventions of letter writing require a formal style which
includes using complete words and sentences.

 Handy Hint: It is a test of English not Latin, so where possible avoid the use of Latin
based acronyms and words.

Here is a list of common abbreviations used in Australia.

Acronym/Short Full Expression Acronym/Short Full Expression
Form Form
Abdo Abdomen mane in the morning
AC before meals min minute
ADL activities of daily living NAD no abnormality detected
& and nocte in the evening
BD/bid 2 times a day OPG orthopantomogram
BP blood pressure P/PR Pulse/Pulse Rate
BW x-rays bite wing x-rays PMH past medical history
C/O complains of PRN as required
cap capsule QID 4 times a day
DOB Date of Birth R right
ECG electrocardiograph tab tablet
F/- fluoride application sid once a day
FBC full Blood Count TDS/tid 3 times a day
FTA failed to Attend w/o without
IV intravenous y/yrs year
h hour ? rheumatic fever possibility of something
hx history 6/h 6 hourly
L left + positive
lab laboratory 3/12 3 months

Exceptions to this rule include abbreviations of measurement. Therefore it is

acceptable to use the following in short form:
Acronym/Short Form Full Expression Acronym/Short Form Full Expression
cm centimeter ml millilitre
g gram mg milligram
kg kilogram mm hg milligram of mercury
 Common Errors
Incorrect
 Her current medications include sid
Metformin 500 mg. mane and nocte,
Glycosamine 5mg.mane and Candesartan
10mg. nocte.
 After discharge from hospital, Mrs.Jones has
been told to take Aperients (PRN) and
Aldomet (250 mg bid).
 I treated Claudia with prednisolone5mg
1t/sid for seven days.
 On examination, there was tenderness and
rebound tenderness over the R. iliac fossa.
 I am writing to refer Mrs. Wilson, a 45yr old
woman who is suffering from signs and
symptoms suggestive of advanced English.
 She presented to me yesterday evening with
abdominal pain mostly in the left iliac fossa
which had been present for the last 24 hrs.
 Her mother died of MI
 On examination she was found to have PR
88/min
 Mr Duane Eddy 57/m is an a urgent referral
regarding an ulcer in R. lateral border of tongue.
 I would appreciate if you could inform me
about her treatment & progress over the next
few days.
 The patient was discharged on Dec. 30 2009.
 Lab work and review was planned for the
next morning.
Referring to a Patient
There are certain conventions which need to be followed when referring to a patient in a formal letter. This
worksheet will explain what you need to know so that you can conform to these conventions.
The basic rules regarding titles are as follows:
 Mr. is used for adult men, married or single


Correct
 Her current medications include a daily dose
of Metformin 500 mg. in the morning and at
night, Glycosamine 5mg.in the morning and
Candesartan 10mg. at night.
 After discharge from hospital, Mrs.Jones has
been told to take Aperients when required
and Aldomet twice a day.
 I treated Claudia with prednisolone 5mg tablet
once a day for seven days.
 On examination, there was tenderness and
rebound tenderness over the right
iliac fossa.
 I am writing to refer Mrs. Wilson, a 45-year-
old woman who is suffering from signs and
symptoms suggestive of advanced English.
 She presented to me yesterday evening with
abdominal pain mostly in the left iliac fossa
which had been present for the last 24 hours.
 Her mother died of myocardial infarction
 On examination she was found to have a pulse
rate of 88 beats per minute.
 On examination she was found to have a pulse
of 88.
 Mr Duane Eddy, a 57 year old male is an a
urgent referral regarding an ulcer in the right
lateral border of tongue
 I would appreciate if you could inform me
about her treatment and progress over the
next few days.
 The patient was discharged on December 30
2009.
 The patient was discharged on 30/12/09.
 Laboratory work and review was planned for
the next morning.
 Mrs. is used for married women including widows
 Ms. is used to refer to both married or unmarried women
 Miss is used for young girls or unmarried women
 Master is used for young boys, but is rare nowadays as it has become old fashioned. It is still commonly
used on an envelope, but not in the body of the letter.

nb Both miss & master are not abbreviations so no punctuation is required.

 Handy Tip 1:
Definitely do not use titles with first names only, i.e Mr Thomas or Mrs. Carol as this is not acceptable. See
below for correct usage.

These titles can be used in the following ways

 I am writing to refer Mr. Hacker (standard)
 I am writing to refer Mr. Thomas Hacker (very formal, usually used above the address or after Re: but not
on the body of the letter.)
 I am writing to refer Thomas (informal and commonly used for children)
 I am writing to refer this patient (commonly used in the opening sentence if patient's name has been
mentioned above as in Re: Mr. Thomas Hacker)

Question: When and how often should I use the patient's name in the letter?
Answer: The standard way is to write the patient's name in full below the opening saluation. Then, use the
patient's name once per paragraph as illustrated below ,after which you can use pronouns. Also, be consistent
in how you refer to the patient. Do not mix up your use of first names and surnames in the letter as this will
only confuse the reader.

 Handy Tip 2:
There is no need to write the patient's name out in full in the introduction if you have stated it below the
salutation i.e Re: Mrs. Carol Brady as it is very clear who you are writing about. In such cases use "this patient"
or title and surname "Mrs. Brady". If you do this you will be following standard conventions.

Example Letter
31 July 2009

The Director
Redeemer Palliative Care Hospital 32 Nelson Drive
St Lucia Queensland, 4050

Dear Sir/Madam,

Re: Mrs. Carol Brady DOB 4 February 1968

I am writing to refer this patient, a 42 year old married woman who was diagnosed with stage 4 ovarian cancer
on 22 May 2009. I would appreciate it if you could provide respite care for her.
 I have been supporting Mrs. Brady and her family for the past 2 months,and she is on palliative care and now
only expected to live for four months. Her husband Mr. Mike Brady is her primary carer,and he has reduced his
work hours to look after her and their children aged 10 and 12. He usually feels that he is exhausted,
emotionally stressed and isolated because he finds it difficult to cope with all the work at home.

Mrs. Brady is depressed and withdrawn and she does want any visitors. In addition, she has not been eating
much recently. Regarding medication, she takes oxycontin and stemitel twice daily and is on a regular panadol.
However, her pain is still increasing.

Could you please do a reassessment of Mrs. Brady’s pain medication as it may need to be increased. Thank you
for looking after this patient and please do not hesitate to contact me if you have any further questions.

Yours sincerely,

Community Nurse

Common Mistakes
Mr. Langer is an only child. Alfie is an only child.
Explanation: Mr. is only used for adult men, so if the
patient is a child you should use their first name.
Thank you for seeing my patient, Master Alfie Thank you for seeing my patient, Alfie Langer, a 7 year
Langer, a 7 year old boy. old boy.
Explanation: Master is somewhat old fashioned and does
not sound "familiar" if used in the body of the letter.
Mr. Peter, a 23 year old young man, presented at my Mr Holmes, a 23 year old young man, presented at my
surgery today complaining of painful wisdom teeth. surgery today complaining of painful wisdom teeth.
Explanation: You can not use titles with first names only.
I am writing to refer Miss. Green for surgical assessment. I am writing to refer Miss Green for surgical assessment.
Explanation: Miss is not an abbreviation so no
punctuation required.
Dear Dr., Dear Doctor,
I am writing this letter.... I am writing this letter....
Explanation: Do not use short forms without the
surname of the person.

Control of Presentation Features

Letter Format
One of the criteria used to assess your writing in the OET exam is Control of Presentation Features. This criterion
assesses the overall presentation of the letter and includes a lot of the features outside the body of the letter
including
 Letter format
 Punctuation
 Capital letters
 Spelling
 This worksheet will describe the characteristics of formal medical correspondence. To do this, the letter has
been broken up into 6 parts.

1. Date: The date should be placed at either the top left or top right of the letter and can be either written
in full or as numbers as follows:

o 21/07/10
o July 21, 2010
o 21st July, 2010

2. Address: The address gives the name and address of the person or facility to whom you are writing.
There are some basic conventions which need to be followed including:

o Capital letters for job titles, names & street names

o Commas not required when the address in separated by lines

Dr. John Howard Dr Ian Hanson Lactation Consultant

1 Wickham Tce Consultant Orthopaedic Breast Feeding Support
Spring Hill Surgeon Riverlea Public Centre 68 Main Street
QLD 4010 Hospital Graham Street Romaville
Riverlea N.S.W 2068

3. Salutation: If the name of the person is included in the case notes then it should be used. This can be
followed by either a comma or full colon.

o Dear Dr. Wilson,

o Dear Dr. Wilson:

If the name of person is not mentioned then you can begin with Sir/Madam

o Dear Sir/Madam,

4. Subject: The subject is a place where information such as the name & age of the patient can be
included. This can save you words in the body of the letter, but be careful not include too much
information here, and definitely no phrases or sentences. Both Re & RE are acceptable.

o Re: Dylan Charles D.O.B.04/12/2009

o RE: Dylan Charles D.O.B.04/12/2009

5. Body: The information in the body of the letter should be divided into paragraphs, with the standard
format for a referral letter being as follows:

o Introduction which includes background information & purpose of writing or chief complaint in
summary form.
o Past medical/social history
o Current condition in detail or discharge plan
o Conclusion, which if time permits, should be specific to the scenario in then case notes.
Note: OET requires the letters to be between 180~200 words approximately. The word length is based on the
body of the letter only.

6. Closer: The closer is the final part of the letter and should be written one space below the last line of
the body. Only the first word in the closer should be capitalised and a comma should following the last
word.

o Yours sincerely,(standard)
o Sincerely yours,
o Sincerely,
o Yours truly, (American style, but gaining popularity in Australia)
o With best regards, (acceptable, but more common as an email ending)

Note: Yours faithfully, is often recommended as a closer when you don't know the name of the person to whom
you are writing. However, in formal medical correspondence it is not advised as it puts you in a subservient
position.

Sample Letter Format from a Physiotherapist

05/02/2010

Mr. Alex Hinges

Southside Physiotherapy Centre
15 Kings Street New Hampshire
N.S.W 2240

Dear Mr. Hinges,

Re: Master Peter MacLean
D.O.B. 17/10/1993

Thank you for taking over the care of Peter, a 17-year-old student who has a history of cystic fibrosis (CF).

Peter was diagnosed with CF when he was born and he needs frequent admissions due to recurrent lung
infections. He lives with his parents and an elder brother. Peter currently takes Pancrease, omeprazole and oral
hypoglycaemics. His self-management program includes active cycle breathing (ACB), positive expiratory
pressure (PEP), flutter and posture drainage (PD). Peter’s fitness is maintained by biking toschool.

He was admitted with an exacerbation of his CF on 02/02/2010 with frequent small and non-productive coughs.
Examination revealed a thin and moderate dehydrated young man with hyperinflated chest. His temperature
was spiking. He had moderately decreased lung function with blood oxygen saturation (SaO2) of 95%. There
were widespread crackles on auscultation. Peter was treated with antibiotics intravenously.

Initial physiotherapy consisted of PD, percussion and vibration. Effective cough techniques were demonstrated.

Peter’s condition has improved and he started gym sessions today. I have arranged for an appointment with
Peter to check the effect of car fumes when he is biking. I will consider a mask to keep his airway moisturised if
the car fumes impact on his breathing.
 Peter will be discharged in 3 days from the medical ward and will require on going care.

Yours sincerely,

Tania Robinson

Physiotherapist

Common Errors
Incorrect Correct
30 Dec. 09 30 December
Explanation: The date should be written in full. 2009 30/12/09
To Dr. Blair Howell
Dr. Blair Howell, Admitting
Admitting doctor Doctor 28
28, George street, George Street
Spring hill, Spring Hill
Queensland 4000 Queensland
4000
Explanation:

1. To not required.
2. Commas not required when the address is
written top at the letter because the
information is separated lines.
3. Capitals required for job titles
4. Capitals required for street names & suburbs.
Dear Dr Jones Dear Dr. Jones,
Explanation: Comma or full colon required Dear Dr. Jones:
Re: Julie Crosby, 25 yr receptionist, single Re: Julie Crosby, 25 years of age
Explanation: Too much information. Best practice is too Re: Julie Crosby, D.O.B 21/07/85
include name and age of patient only. Other
information such as gender, profession, marital status
and so forth can be included in the opening sentence.
Your's sincerely, Yours sincerely,
Explanation: The possessive form is used before nouns,
not adverbs
Regards, With best
Mary Smith regards, Mary
Charge Smith Charge
Nurse Nurse
Explanation: Informal, email style closer
Thanks, Thank you for your assistance regarding this patient.
Mary Smith
Charge Yours sincerely,
Nurse Mary Smith
Explanation: Too casual Charge Nurse
Hello Dr. Jones, Dear Dr. Jones
Hi Dr. Jones
Explanation: Too casual
 The Comma
The comma is the most frequently used punctuation mark within sentences. Used correctly it allows the writer
to separate a group of words or phrase from other parts of a sentence. This is necessary in order to add useful
information in a sentence. The information can be added at the beginning, the middle or the end. However if
commas are not used or overused, the meaning can be affected and the flow of information disrupted. By
understanding the basic rules presented in this section you should be able to develop a good understanding of
how and when to use commas in referral letters.

Rules of Usage

1. The Adverbial Phrase: The adverbial phrase can be used in referral letters to provide information such as a
time, place, context, emphasis or mood in the sentence which is to follow and it is commonly separated by a
comma

o Context: On examination, there was slight tenderness in the right fornix.

o Date: On today’s visit, the patient was pale and sweaty.
o Emphasis: Please note, the patient is allergic to penicillin.
o Mood: Unfortunately, the patient’s condition has worsened. Note, mood or comment adverbs,
such as unfortunately or regrettably convey the health professionals concern toward the
patient’s condition and are therefore effective ways of displaying emphathy.
o Contrast: The patient's condition has improved. However, a follow up visit is required.

Sentence Structure
Adverbial Subject Verb Object/
Phrase Compliment
blank I suspect the patient has
developed
ectopic
pregnancy.
Comma preferred Unfortunately, I suspect the patient has
developed
ectopic
pregnancy.
blank Abdominal revealed slight right iliac fossa
examination tenderness.
Comma preferred On examination, slight right iliac fossa was revealed. blank
tenderness
blank Clinical examination revealed a large mesioincisal
of hard tissues fracture.
Comma preferred On examination, a large mesioincisal was revealed. blank
fracture
Comma preferred Regarding her medical she has been suffering asthma for which she
history, from uses a ventolin
inhaler.
Comma preferred On review today, there was no improvement in
her condition.
Comma preferred In terms of his he is a heavy smoker and a
medical history, heavy to moderate
drinker.
Comma preferred Please note, the patient has an appointment with
his physiotherapist at
10 o'clock on Monday.
Comma preferred In addition, there are composite and
amalgam restorations
on several teeth.

 Handy Hint: Do not put a comma between a subject and a verb or a verb and an
object.
2. Appositives: This is a noun or a noun phrase that is placed after another noun to explain or identify it. It has a
very important use in the introductory sentence of referral letters as follows.

o Mr Smith, an 80 year old widow, was admitted to hospital with complaints of heart palpitations.
o Thank you for seeing Jordan, a 10 year old boy who presented at my clinic today with a main
concern of pain in tooth 54.
o I am writing to refer Mrs. Bradley, a 42 year old married woman who is suffering from cancer.

3. Conditional Sentences: These sentences are frequently used in the conclusion of a referral letter and the rules are
as follows:

o Use a comma if the if clause is at the beginning of the sentence.

 If you could take over her antenatal care,it would be much appreciated.
 If you have any further questions regarding this patient, please don’t hesitate to call me.
o Don’t use a comma if the if clause is at the end of the sentence.
 It would be greatly appreciated if you could take over her antenatal care.
 Please don’t hesitate to call me if you have any further questions regarding this patient.

4. Complex sentences:

o Use a comma if the dependent clause is at the beginning of the sentence.

 In case of irritation, redness or swelling, please consult your doctor.
 When the results become available, I will forward them to you.
 Because of her deteriorating condition, the patient was admitted to hospital.
o Don’t use a comma if the dependent clause is at the end of the sentence.
 Please consult your doctor in case of irritation, redness or swelling.
 I will forward the results to you when they become available.
 The patient was admitted to hospital because of her deteriorating condition.

5. Comma Splices: A comma splice is two sentences joined together with a comma, but no conjunction. This is an
error as the information must be either joined with a coordinating conjunction such as and/but/or or a new
sentence must be started.

o He does not have any dental experience, he is worried about the pain.(incorrect)
o He does not have any dental experience and he is worried about the pain.(correct)
o He does not have any dental experience. Therefore, he is worried about the pain.(correct)

6. Noun Clauses beginning with that should not be separated by a comma.

o It is also important to know, that a re-check is organised for the 31.5.2009 at 10:30 in order to
 remove the suture. (incorrect)

o It is also important to know that a re-check is organised for the 31.5.2009 at 10:30 in order to
remove the suture.(correct)

7. Use commas to separate three or more words, phrases, or clauses written in a series.The final word does
not require a comma and it should be separated by a conjunction such as and or or

o Mrs. Olsen has a history of hypertension, hypothyroidism, glaucoma for which she is on regular
medication. (incorrect)
o Mrs. Olsen has a history of hypertension, hypothyroidism and glaucoma which is on regular
medication. (correct)

Common Errors
Incorrect
1. On review today Mr Walker has reduced
smoking from 20 to 10 cigarettes per day.
2. On examination today there was a soft
fluctuant swelling palpable on the left
cheek
3. Regrettably she has problems with breast
feeding and caring for the baby.
4. Please note he has a prosthetic heart valve.
Correct
1. On review today, Mr Walker has reduced
smoking from 20 to 10 cigarettes per day.
2. On examination today, there was a soft
fluctuant swelling palpable on the left
cheek
3. Regrettably, she has problems with breast
feeding and caring for the baby.
4. Please note, he has a prosthetic heart valve.

Comma preferred for adverbial phrases. Refer to rule 1

above.
1. I am writing to refer Mr. Jones a 57 year old man
who was admitted to hospital on the 18th of
July, diagnosed with myasthenia gravis.
2. Mr Jones, a 57 year old man was admitted to
hospital on the 18th of July, diagnosed with
myasthenia gravis.
Comma required for appositives. Refer to rule 2 above.
1. I am writing to refer Mr. Jones, a 57 year old
man who was admitted to hospital on the
18th of July, diagnosed with myasthenia
gravis.
2. Mr Jones, a 57 year old man, was admitted to
hospital on the 18th of July, diagnosed with
myasthenia gravis.

Apply the comma rule for conditional sentences. Refer

to rule 3 above.

Apply the comma rule for complex sentences. Refer to

rule 4 above.
 He has an allergy to nuts, once he was  He has an allergy to nuts and was once
hospitalised for severe anaphylactic reaction. hospitalised for severe anaphylactic reaction.

Refer to rule 6 above.

 Please note that, Daniel has an allergy to  Please note that Daniel has an allergy to
peanuts. peanuts.

Apply the comma rule for comma splices. Refer to rule

5 above.
  Mr.Farrah, presented at my surgery today  Mr.Farrah presented at my surgery today
complaining of pain radiating from his left ear complaining of pain radiating from his left ear to
to his front teeth. his front teeth.

Do place a comma between the subject and verb of a

sentence.
 Initial examination revealed, complete
edentulous upper and lower jaws with
healthy soft tissue.
 I am writing to request, visits for this family.
 Initial examination revealed complete
edentulous upper and lower jaws with
healthy soft tissue.
 I am writing to request visits for this family.

Do place a comma between the verb and object of a

sentence.

Quick Guide to Commas

1. Use commas to separate independent clauses when they are joined by any of these seven coordinating
conjunctions: and, but, for, or, nor, so, yet.
2. Use commas after introductory a) clauses, b) phrases, or c) words that come before the main clause.

3. Use a pair of commas in the middle of a sentence to set off clauses, phrases, and words that are not essential
to the meaning of the sentence. Use one comma before to indicate the beginning of the pause and one at the
end to indicate the end of the pause.

4. Do not use commas to set off essential elements of the sentence, such as clauses beginning with that
(relative clauses). That clauses after nouns are always essential. That clauses following a verb expressing mental
action are always essential.

5. Use commas to separate three or more words, phrases, or clauses written in a series.

6. Use commas to separate two or more coordinate adjectives that describe the same noun. Be sure never to add
an extra comma between the final adjective and the noun itself or to use commas with non-coordinate
adjectives.

7. Use a comma near the end of a sentence to separate contrasted coordinate elements or to indicate a distinct
pause or shift.

8. Use commas to set off phrases at the end of the sentence that refer back to the beginning or middle of the
sentence. Such phrases are free modifiers that can be placed anywhere in the sentence without causing
confusion.

9. Use commas to set off all geographical names, items in dates (except the month and day), addresses (except
the street number and name), and titles in names.

10. Use a comma to shift between the main discourse and a quotation.

11. Use commas wherever necessary to prevent possible confusion or misreading.

 Capitalisation
Correct use of capitals is an important area to master when writing referral letters. Study the rules of usage
below to ensure you meet the standard conventions.

Rules of Usage

1. Medications and Diseases

o Capitals are required for proper nouns. Proper nouns include the brand name of a drug or
registered trademark of the manufacturer.
 Ritalin
 Voltaren
 Zocor
o The chemical constituent should be written in lower case.
 penicillin
 amoxicillin
o Names of diseases should always be lower case.
 bowel cancer
 high blood pressure
 diabetes
 epilepsy
o Eponyms: Some medical conditions are named after the person who discovered it. In this case
the first word should be capitalised.
 Parkinson’s disease
 Bell’s palsy
o Names of medical equipment do not require capitals.
 orthopantomogram
 x-ray
o Body parts should always be lower case
 heart
 adrenal gland
 knee

2. Proper Nouns: Proper nouns name something specific as in the examples below. These
words must always be capitalised.

o Job titles
 The Lactation Consultant, Mater Hospital
 The Veterinary Eye Specialist, University of Queensland
o Institutions
 Mary Jones was admitted to Spirit Hospital.
 Dr. Bloomfield works at Weller Point Medical Centre.
o Places including addresses
 168 Wickham Terrace, Spring Hill
 12 Logan Road, Mt Gravatt
 36 Barmore Street, Holland Park
o Titles when they precede the name of a person
 The patient was seen by Doctor Smith.
 Nurse Jones is in charge of the patient's care.

3. Common Nouns: Common nouns do not name any specific institution, place, person or profession.
These words do not need to be capitalised.

o The patient was admitted to hospital.

 o The patient does not have a family doctor.
o Steve is a teacher.
o Yoshiro is a doctor.
o Reza is a dentist.

4. Holidays, months, days of the week all need to be capitalised. However seasons do not.

o The baby was born on Christmas Day.

o The patient was admitted to hospital on January 12.
o Please come and see me on Wednesday.
o The vaccination will be available in spring.

5. The pronoun "I" must always be capitalised.

o It was I who treated the patient.

6. Capitalise the first word of a salutation and the first word of a complimentary close.

o Dear Dr. Jameson:

o Yours sincerely,

Common Errors
Incorrect
 His medical history shows that he is Epileptic.
 Also, I have given Dycal base on 1.1 and
dressed it with Glass Ionomer Cement.
 The patient was diagnosed with Type 2 Diabetes.
 Mrs. Marsh has a history of
Hyperthyroidism, Hypertension and
Glaucoma.
 The patient is allergic to Penicillin.
 The patient suffered from severe Abdominal
pain.
Correct
 His medical history shows that he is epileptic.
 Also, I have given dycal base on 1.1 and
dressed it with glass ionomer cement.
 The patient was diagnosed with type 2 diabetes.
 Mrs. Marsh has a history of
hyperthyroidism, hypertension and
glaucoma.
 The patient is allergic to penicillin.
 The patient suffered from severe abdominal
pain.

Refer to rule 1 above.

 Mr. duane thomson presented at my clinic  Mr. Duane Thomson presented at my clinic
today with the complaint of a broken posterior today with the complaint of a broken
tooth. posterior tooth.
 The director of nursing  The Director of Nursing
 emergency department  Emergency Department
 Mater hospital  Mater Hospital
 84 Monash road  84 Monash Road
 The patient was seen by doctor Jones.  The patient was seen by Doctor Jones.

The above words are all proper nouns. Refer to rule 2

above.
  As per the General Practitioner’s order, we are
doing daily home visits and wound dressing
and also assisting him with his showers.
 Please see your Pharmacist for advice.
 Ms. Gatsby is a University student.
The above words are all common nouns. Refer to rule 3
above.
 The patient first visited my surgery in march,
2008.
 Mrs. Green will be discharged from
hospital on wednesday.
 Symptoms of hay fever are worse in Spring.
Refer to rule 4 above.
 The patient requested that i prescribe
antibiotics for the virus.
Refer to rule 5 above.
 dear Dr. Roberts:
 yours sincerely,
Refer to rule 6 above.
Common Errors
Common Mistakes Regarding Physical Description
Incorrect
Advice was given to reduce her weight.
After the verb reduce it is not necessary to follow with a
pronoun. So you is not required. Simply say:
I advised him to reduce weight, or, you need to reduce
weight.
In addition, she had lost her weight.
After the verb lose it is not correct to follow with a
pronoun.
He is now obese with a 99kilos weight and a 170cm
height.
The use of the correct verb & noun form and associated
grammar is difficult. Refer opposite for correct usage.
1. Today’s examination revealed multiple missing
teeth, various carious lesions and a periodontal
pocket of depth 4-9mm.
 As per the general practitioner’s order, we are
doing daily home visits and wound dressing
and also assisting him with his showers.
 Please see your pharmacist for advice.
 Ms. Gatsby is a university student.
 The patient first visited my surgery in March,
2008.
 Mrs. Green will be discharged from
hospital on Wednesday.
 Symptoms of hay fever are worse in spring.
 The patient requested that I prescribe
antibiotics for the virus.
 Dear Dr. Roberts:
 Yours sincerely,
Correct
1. Advice was given to reduce weight.
2. The patient was advised to reduce weight.
3. A reduction of weight was advised.
1. In addition, she had lost weight.
2. In addition, she has lost a further 11 kg of
weight over the past 2 months.
3. In addition, the patient’s weight has
significantly reduced from 61 kg to 50 kg over
the past 2 months.
1. He is now obese with a weight of 99 kg and a
height of 170cm. (noun form)
2. He weighs 99 kg and is 170cm tall. (verb
form)
3. He weighs 99kg and is 170cm in height. (verb
form)
1. Today’s examination revealed multiple
missing teeth, various carious lesions and a
periodontal pocket depth of 4-9mm.
 2. There are several periodental pockets with 2. There are several periodontal pockets which
about 4-9 mm in depth. are about 4’9 mm in depth or
3. There are several periodontal pockets with a
Correct word order is: depth of about 4-9 mm.
Depth of 4-9mm 4. His height is 173cm.
Height of 173cm
Length of 20 m
Weight of 78kg

3. His height was 173cm. Weight can change but

height cannot so don’t use past tense.

1. He was overweight 85 Kg with respect to 1. He was overweight at 85 kg with respect

his height 173 cm. to his height of 173 cm.
This sentence is a shortened version similar to
the case notes. It is important to write in full
sentences.

Difficult Words
The English language is governed by rules. However, there are also many exceptions to these rules and words
which do not follow the normal or expected pattern are those which often cause problems. Study this list
carefully so that you can improve your grammatical accuracy and knowledge.

Complain Vs Complaint

Complain is a verb

 The patient complained of severe abdominal pain.

Complaint is a noun

 The patient presented with a complaint of severe abdominal pain.

Note 1: Complaint is a countable noun. so it can be used in the plural form or singular
with an article. Note 2: The two main prepositions used with complain are: complain of
& complain about.

 Mr. Cochrane presented with complaints of nausea, headache and fever. (plural)
 Mr. Cochrane presented with a complaint of nausea. (singular with article)

Incorrect Correct
  The patient complaints of chest pain and her
blood pressure is high.
 The patient presented with a complain of chest
pain.
 The patient presented with complaint of chest
pain.
 He presented to my office on 23/03/2008
complaining on severe pain associated with the
lower left first molar.
 The patient complains of chest pain and her
blood pressure is high.(verb)
 The patient presented with a complaint of
chest pain.(noun)
 The patient presented with a complaint of
chest pain. (article required)
 He presented to my office on 23/03/2008
complaining of severe pain associated with the
lower left first molar.

Suggest & Recommend Vs Advise

Suggest, recommend and advise are all words commonly used in referral letters to report information were
given to the patient. However their rules of use differ and result in errors. Here are some examples of their
correct and incorrect usage.

Incorrect
 I have suggested him to see you next week.
 I suggested her to return in morning as she
required further blood test and assessment.
 I recommended him to rest for 3 days.
Explanation:The words suggest & recommend
cannot be followed by an object pronoun such as
him/her whereas advise can.
Correct
 I suggested (that) he see you next week.
 I advised him to see you next week
 I suggested (that) she return in morning
as she required further blood test and
assessment.
 I advised her to return in morning as she
required further blood test and assessment.
 I recommended (that) he rest for 3 days.

Explain Vs Tell

Explain and tell also have different rules which cause confusion
Incorrect
 I explained them that unsuccessful
conception was not unusual in their case.
 I have already explained the couple the basic
advice regarding conception.
Explanation: The word explain cannot be followed
by a pronoun or noun without the preposition to
whereas tell can.
Correct
 I explained to them that unsuccessful
conception was not unusual in their case.
 I told them that unsuccessful conception
was not unusual in their case.
 I have already explained to the couple basic
advice regarding conception.
 I have already told the couple basic advice
regarding conception.

Advise Vs Advice
Advise is a verb

 We advise patients on how to take their medication.

 Advice is a noun

 We give advice or provide advice to patients on how to take their medication.

Note 1: The noun advice is uncountable so it cannot be used in plural form. i.e. advices is incorrect as is an advice.

 I gave some advice to the patient regarding her medication.

Note 2: The pronunciation is different: advise advice

Incorrect
 It would be greatly appreciated if you could
make a visit to this family and advice his
parents regarding the recommended vaccines
for both children.
 I am writing to refer this patient to you for an
advice regarding the management of his
bilateral inguinal hernia.
 I gave an advice to the patient
regarding her medication.
 I gave advices to the patient
regarding her medication.
 Please advice the patient on how and when
to take their medication.
Correct
 It would be greatly appreciated if you could
make a visit to this family and advise his
parents regarding the recommended vaccines
for both children. (verb)
 I am writing to refer this patient to you for
advice regarding the management of his
bilateral inguinal hernia(noun)
 I gave some advice to the patient
regarding her medication.(noun)
 I gave advice to the patient
regarding her medication.(noun)
 Please advise the patient on how and when
to take their medication. (verb)

Request
Request can be both a verb and noun.

Request as a verb
 The patient requested painkillers. (verb form)

Request as a noun

 The patient made a request for painkillers. (noun form: request+for)

Incorrect
 The patient requested for new dentures.
 Ms. Green requested about IVF treatment.
Explanation: The common mistake is to use the verb
form plus preposition which incorrect.
Correct
 The patient requested new dentures. (verb)
 The patient made a request for new dentures.
(noun)
 Ms. Green requested IVF treatment.(verb)
 Ms.Green made a request for IVF treatment.
(noun)
 Affect Vs Effect
Affect is a verb

 The patient has not been affected by the treatment.

Effect is a noun

 The treatment has had no effect.

Note: The pronunciation is the same.

Incorrect Correct
 She has also been effected by glaucoma for the  She has also been affected by glaucoma for the
past 4 years. past 4 years. (verb)
 The side affects of this medication are unknown.  The side effects of this medication are
unknown. (noun)

Widow or Widower

 Widow (noun) refers to a woman whose husband has died and who has not remarried.
 Widower (noun) refers to a man whose wife has died and who has not remarried.
 Widowed (adjective) refers either a man or woman whose spouse has died and has not remarried.

Incorrect
 I am writing to refer Mrs. Saunders, a 58-
year-old widowed who admitted with pain,
dehydration and nausea.
 I am writing to refer Mr. Saunders, a 60-
year-old widow who complained of pain in
his upper right second molar.
Correct
 I am writing to refer Mrs. Saunders, a 58-
year-old widow who admitted with pain,
dehydration and nausea.(noun)
 I am writing to refer this patient a 58-
year-old widowed woman who admitted
with pain, dehydration and
nausea.(adjective)
 I am writing to refer Mr. Saunders, a 60-year-
old widower who complained of pain in his
upper right second molar.(noun)

History
History is always present, never past because you can’t erase it! Therefore you need to use simple present tense
not past tense when using this expression.
Incorrect Correct
  Mrs. McGowan had a history of heart  Mrs. McGowan has a history of heart
palpitation of 3 day duration. palpitation of 3 day duration.

Allergy Vs Allergic

Allergy is a countable noun

 Michael has no known allergies.(plural)

 Michael has a peanut allergy. (singular)

Allergic is an adjective

 Michael is allergic to peanuts

 Incorrect
 In addition, he is known allergic to nuts for
which he was admitted to hospital with
anaphylaxis 2 years ago.
 Regarding his medical history he is allergy to
sulphur containing drugs.
Correct
 In addition, he has a known allergy to nuts for
which he was admitted to hospital with
anaphylaxis 2 years ago.(noun)
 In addition, he is known to be allergic to
nuts for which he had been admitted in the
hospital with anaphylaxis 2 years
ago.(adjective)
 Regarding his medical history he has an
allergy to sulphur containing drugs.(noun)
 Regarding his medical history he is allergic to
sulphur containing drugs.(adjective)

Confident Vs Confidence
Confident is an adjective

 The patient is not confident in her ability as a mother.

Confidence is a noun

 The patient lacks confidence in her ability as a mother.

Incorrect Correct
 The patient has not confident social situations.  The patient has no confidence in social
 The patient is not confidence in social situations. situations. (noun form)
 The patient is not confident in social
situations. (adjective form)

a few/few & a little/little

Few and a few is used with plural nouns, and little and a little is used with uncountable nouns. Little and few
have negative connotations and are similar in many to not much/ not many. A little and a few have positive
connotations and are similar in meaning to some. Mixing up these words therefore will completely change the
meaning of the sentence.

Incorrect
 The patient has reduced speech output and a
little eye contact.
 There are few ways to help identify the
possibility of threadworms such as checking the
anus of your children at night and frequent
scratching.
Correct
 The patient has reduced speech output and
little eye contact.(negative connotation
required here)
 There are a few ways to help identify the
possibility of threadworms such as checking
the anus of your children at night and frequent
scratching.(positive connotation required)
 during/while
During is followed by a noun

 During hospitalisation the patient made a full recovery.

 The patient had many visitors during his stay in hospital.

While is followed by a phrase or gerund: ing

 While in hospital, the patient made a full recovery.

 The patient had many visitors while recovering in hospital.

Incorrect Correct
 He twisted his ankle during playing squash 3  He twisted his ankle during a game of
months ago. squash 3 months ago.
 He twisted his ankle while playing squash 3
months ago.

following/followed by

Incorrect Correct
 She was admitted to our hospital followed by a  She was admitted to our hospital following a
collapse at home with dehydration,nausea and collapse at home with dehydration, nausea and
severe pain. severe pain.

Incorrect as it means the patient was admitted to Correct as it means the collapse occurred before being
hospital first, then collapsed. admitted to hospital.

Years Vs Year

Incorrect Correct
I am writing to refer this patient,63 years old man who 1. I am writing to refer this patient, a 63- year-
lives alone. old man, who lives alone.
In this sentence there are two mistakes: 2. There are two 63-year-old men in the waiting
1. the expression is a phrase and therefore room.
requires an article “a “ to precede the phrase
a 63-year-old man. An article is required
because the noun man is singular. Compare
with: There are two 63-year-old men in the
waiting room.
2. Years is an adjective in this sentence (it
describes the age of the man) and adjectives
are uncountable.
This patient is 63 year old. This patient is 63 years old.
In this sentence the word years is a noun preceding an
adjective old. Nouns can be countable so in this case
you must make it plural.

Her father died at 50 year old of bowel cancer 1. Her father died at 50 years of age of bowel
In this case at is a preposition and needs to be cancer
followed by a noun or noun phrase, rather than the 2. Her father died at the age of 50 of bowel
adjective” old”. See column on the right for possible cancer
correct choices. Year is a noun in this case so it should 3. Her father died when he was 50 years old of
be written in plural form. bowel cancer.
Other examples

1. In addition, he had a habit of thumb sucking
until age of five years.
2. In addition he had a habit of thumb sucking
until he was five years age.
3. Regarding the medical history, Alfie has a
history of thumb sucking until the age of 5
years,
1. In addition she has fillings, crowns, good
dental hygiene and a 13 years old chrome
/cobalt removable partial denture.
Years is an adjective in this sentence (it describes
the age of the denture) and adjectives are
uncountable.
1. In addition, he had a habit of thumb sucking
until the age of five.
2. In addition, he had a habit of thumb sucking
until he was five years of age.
3. In addition, he had a habit of thumb sucking
until he was five years old.
1. In addition she has fillings, crowns, good
dental hygiene and a 13 year old chrome
/cobalt removable partial denture.

Phrasal Verbs and Prepositions

A to Z of Phrasal Verbs and Useful Vocabulary
Letter Expression Example sentence

a.  admitted to  The patient was admitted to our hospital in March 2008 for
 associated with the first time.
 advised to
 Mr. Booth first came to see me on 12/08/08 complaining of
 advice on shortness of breath which was worse when he was lying
down. It was associated with a tightness in the chest and
 allergies coughing.
 allergic to  She was advised to return the next day for a blood test and
 arrived at
follow up consultation. (verb)
 arrived in
 For both children advice on recommended vaccines
will be necessary. (noun)

 She is not on any medication and has no known allergies.

 Please note, the patient is allergic to penicillin.

 The patient arrived at my surgery in a depressed state.

 The family arrived in Australia in 2007

b.  believe  I believe the patient needs urgent assessment and hospital
 borderline admission
 She was noted to be overweight and has borderline
hypertension.
c.  consistent with  I am writing to refer Mr. Walker a 40 year old married
 commence patient, presenting with signs and symptoms consistent
 commence on with prostatic enlargement.
 confidence in  IV fluids were commenced in order to improve hydration.
 Therefore I commenced him on omeprazol 20 mg daily and
strongly advised him to stop smoking cigarettes and stop
drinking alcohol. (active)
 She was commenced on 15gram alepam 1 tablet nightly for
her current anxiety and sleeplessness. (passive)
 She lacks confidence in caring her baby in terms of
breast feeding and bathing.
d.  discharge on  He will be discharged on the 12th of August.
 deteriorate  Since 28th of July her condition has deteriorated with
 deny occasional disorientation.
 difficulty in
 She denied vomiting and she was vague reporting about
 diagnosed with
 diagnosis of laxatives.
 Mr. MacIntosh presented to me with the complaint
of difficulty in passing urine.
 I am writing to refer my patient, Fletcher, a nine year old
Labrador cross dog who is diagnosed with high grade
lymhoma. (verb)
 Histological results confirmed the diagnosis of high grade
lymphoma.(noun)
e.  evidence of  Examination findings revealed evidence of an enlarged
 enclosed prostate.
 I have enclosed the radiograph for your convenience.
f.  to follow  The patient was advised to follow a low fat diet.

h.  history  The patient first attended me yesterday evening with a

one day history of lower abdominal pain
 Mr. Abrahim has a positive family history of prostate cancer
i.  indicate  The family has indicated that they need an interpreter who
speaks Farsi or Arabic during follow-up visits with this
 indicative of family.

 However, there was slight swelling in the right groin

 inconspicuous indicative of inguinal hernia

 His family and social history is inconspicious.

k.  known  She is a known asthmatic since childhood and is on
Budesonide inhaler for the same.
m.  to make an  I have made an appointment for her through
appointment your receptionist.
n.  on examination  On examination, her blood pressure was 180/90 mm Hg
with a regular pulse of 70 beats per minute.
o.  occasions  Today she presented very anxious and depressed as she had
noted some blood in her motions on two separate
occasions.
p.  provisional  Provisional diagnosis suggests prostate cancer.
 present at  Mr Gates presented at my clinic yesterday at 7pm with a
 present to complaint of lower back pain.
 Today, he presented to me complaining of a regular dull
ache in the groin.
q.  queries  If you have any further queries, please do not hesitate to
contact me.
r.  reveal  Examination today revealed a significantly increased right
 risk factors groin swelling.
 a routine recovery  His risk factors include: smoking 20 cigarettes per day, lack
 reluctant to of exercise and a strong family history of hypertension.
 rule out  He has made a routine recovery and his wounds appear to
 remarkable findings
be healing well.
 He is reluctant to seek treatment.
 I believe she needs an urgent assessment to rule out
bipolar disorder
 There were no other remarkable findings.
s.  suggestive of  Miss Jones is suffering from the signs and symptoms
suggestive of ectopic pregnancy.
 suspicious of  I am writing to refer this patient, a 60-year-old
women,with symptoms suspicious of bowel
 suffering from malignancy
 signs and symptoms  Ms.Tylor has been suffering from diabetes and she is
administering insulin injection by herself.
 He is a 40-year-old man who is suffering from signs and
symptoms suggestive of peritonitis with perforated gastric
ulcer.
t.  treated with  He also has been suffering from hypertension which has
been treated with Atenolol 50 mg daily.
u.  underlying  I would appreciate your assessment of this girl to find out
 under control whether he has any underlying psychological problems.
 uneventful  Currently, her pain is under control with medication and
 urgent she is tolerating fluids.
 unremarkable  Her second pregnancy and delivery were uneventful.
 to undergo  I would appreciate if you could give urgent attention to
treatment/surgery/an Mrs. Woods' problem.
operation  Cardiovascular examination was unremarkable and her
electrocardiogram was normal.
 She underwent colonoscopy three years ago which was
normal. (simple past)
 During hospitalization, the patient has undergone an
electromyogram and X-ray. (present perfect)
v.  vital signs  Her vital signs were normal, but she was overweight (85
kg). Therefore she was advised to reduce weight and do
exercise.
w.  with a complaint of  Mr Gates presented at my clinic yesterday at 7pm with a
complaint of lower back pain.

Prepositions
Prepositions are a difficult area of language to fully master as their usage is not governed by strict rules. The
best way to learn prepositions is by regular reading so that you can slowly absorb and become comfortable with
their correct use. However, it is possible to memorise the correct use of a selection of prepositions in order to
use them accurately in writing the referral letter.
 Prepositions of Time
In: In is used for longer On: On is used for days At: At is used for the Some words require
periods of time and dates and some time of day and for no preposition
time expressions some expressions
 In November  On Monday  At 6 o'clock  Yesterday
 In Spring  On 20 November  At night  Today
 In 2006  On Christmas day  At lunchtime  Tomorrow
 In the past  On his birthday  At that time  Last week
 In the future  On review  At the moment  This week
 In the morning  On examination  At the age of 45  Next week
 In the afternoon  On investigation  At birth
 In her childhood  On presentation
 In his twenties  On two occasions

Prepositions of Place
In: In is used for inside of On: is used for the surface At: At is used for a place of
something area of something activity
 In Australia  On the skin  At home
 In hospital  On the ground floor  At work
 In surgery  At the wound site
 In the stomach  At the clinic

Common Errors
Incorrect Correct
 His father died of cancer during the age of 50.  His father died of cancer at the age of 50.

 In examination today, the patient was  On examination today, the patient was
anxious and distressed. anxious and distressed.

 Initial examination on today revealed  Initial examination today revealed inflammed

inflammed gums. gums.

 On December 2006, the patient had his wisdom  In December 2006, the patient had his wisdom
teeth removed. teeth removed.

 The patient's family arrived at Australia in last  The patient's family arrived in Australia last year.
year.
 Cohesion
Useful signal markers
Letter Signal Marker Example
Sentence
a.  as well  She suffers from oedema as well as bladder incontinence
as and only tolerates fluids.
 as a result of
 This child was admitted with Acute Meningoencephalitis as
a result of a complication following Mumps.
 as a result
 Let me inform you that that the patient has proven to be
uncooperative during his dental treatments. As a result, I
would recommend the treatments be carried out with a
general anaesthetic.
 along with
 On vaginal examination cervical excitation was noted along
with tenderness in the right fornix.
 apart from this
 She looked very anxious and was having trouble sleeping.
Apart from this, no abnormalities were found on rectal,
 at that time
cardiovascular and respiratory examinations.

 Initially, I saw the patient six months ago when she

complained of constipation. At that time, her physical
examination was normal.
b.  besides that  The patient has smoked 40 cigarettes a day for 25-30
 because of this years. Besides that he has type 2 diabetes.
 based on  He smokes 20 cigarettes and drinks 2 beers every day.
Because of this, he has been told to cease smoking and to
reduce alcohol.
 Furthermore, a fine needle aspiration was taken and was
investigated. Based on that, I suggest the dog has
developed lymphoma.
c.  consequently  The depth of periodontal pocket was 3.4mm.Consequently,
he has undergone extensive treatment for carious lesions
and oral hygiene maintenance.
d.  during  During hospitalization, his vital signs have been monitored
and he has been assisted with his showers.
 duration  On 15/2/08, she presented complaining of lower abdominal
pain of 1 day duration.

 despite  Despite various dental treatments and regular dental

cleaning, his general gum condition is only fair.
f.  for this reason  Mr. Fox's blood pressure was elevated and he was
overweight. For this reason the patient was advised to do
exercise and follow a healthy diet.
h.  hence  The carious lesions on 65 are reasonably deep and hence
the tooth has to be extracted.
 however
 The patient regularly visits the dentist and her oral hygiene
status is good. However, her gums are inflamed.
i.  in terms of  In terms of her medical history, she has mild hypertension
and a 12 year history of diverticulitis.
 I have prescribed agleam in order to reduced anxiety.
 in order to
 in addition
 Regarding the medical history, Alfie had a history of thumb
sucking until the age of 5. In addition, he is epileptic and
 in the meantime
uses dylantin to control the attacks.
 I have planned to review him in two months to monitor his
blood pressure and smoking reduction. In the meantime, I
 in case of
believe he needs urological assessment.

 In case of any irritation, redness or swelling of the skin,

discontinue the treatment and consult your doctor
immediately
m.  may I remind you  May I remind you that both the teeth will require root
that…. canal treatment and crown.
 my main concern is  My main concern is that the patient is reluctant to
that……. breastfeed and confident in caring for her baby.

n.  It should be noted  It should be noted that they may have a problem with
communicating in English as they understand limited
English.
o.  over……  Over the past week, she has remained free from severe
pain and has been tolerating a fluid diet.
 She first presented to me on 3.7.06 with several episodes
of heart flutter over the previous few weeks.
 on review today,
 On review today, the patient has reduced smoking to 10
cigarettes a day, attended gym twice a week and lost 7kg so
far.
p.  please note  Please note, he has an allergic reaction to nuts.

r.  regarding  Regarding his medical history, Jordan suffers from eczema

and asthma for which he receives treatment twice a year.
 Regrettably, she complains of mild constipation and
 regrettably weakness.
 Recently, she has been prescribed Karvea 150mg and
 recently Oroxine 0.1mg per day, Timoptol Eye Drops 0.5% twice a
day and Normison 10mg as required.
s.  since then  His urinalysis and examination were normal except obesity
and borderline hypertension. Since then, he has been doing
regular exercise and has managed to lose 8kg of weight
t.  therefore  Her vital signs were normal, but she was overweight (85
 the reason for kg). Therefore she was advised to reduce weight and do
exercise.
 The reason for the referral is to consider a possible
prostate biopsy regarding the patient’s condition.
u.  up until now,  Up until now, Mr. Hutton has lead a very unhealthy life.
 unfortunately  Unfortunately, she is not expected to survive more than 3
months.
w.  with regard to  I am writing with regard to this patient, a 57 year-old
married man who is under our care with the diagnosis of
myasthenia gravis.
 Example Cohesive Paragraphs
Doctors

Initially, I saw Mr. Jones last month when he came for check-up. At this time his blood pressure showed a mild
elevation (165/90).Also his weight was above the normal limit (85 kg while his height is 173 cm). However, the
cardiovascular examination and the urinalysis were normal. Therefore I advised him to lose weight, to stop
smoking cigarettes and to come for a review visit within one month. A prostate specific antigen test was
requested to be done before the next visit.

Dentists
Initial examination on 20/ 02/ 2008 revealed that 54 has a temporary filling with a cavity extending through the
furcation. Based on the bitewing radiological findings, I advised both 54 and 65 be extracted along with the
construction of a space maintainer. Moreover I advised the filling of carious 55 and fissure sealant for all 6’s. In
my view, general anaesthesia is the proper sedation as the patient is known to be uncooperative in a dentist
chair.

Nurses
When admitted to this hospital, Mr. Jagger complained of haemetemesis, anorexia, dizziness associated with
weight loss and anaemia. He also was suffering from severe epigastric pain after meals. Therefore, his stool was
examined and an endoscopy has been performed.

Sentence Structure

Compound Sentences and Coordinating Conjunctions

When writing referral letters it is necessary to take information from the case notes and write it in complete
sentences. The most basic way to do this is as a simple sentence. Simple sentences commonly contain a subject,
verb and object and are known as independent clauses.
Example: The patient is allergic to penicillin.
This method is suitable for information which is not connected to other information in the case notes. However,
it is more common to group information which is related into compound sentences. In the sentence below ,two
ideas are joined by the conjunction and. Note that the subject for each clause is different and each clause can
function as a complete sentence
Example: I prescribed Panadol for his hand pain and he was advised to reduce weight and do exercise.
Compound sentences are joined by conjunctions and they show the relationship between the ideas. The most
common conjunctions are:
and = the second clause contains a similar idea as the first
Example: She does not smoke and (she)drinks alcohol rarely.
but = the second clause contains an contrasting idea
Example: She does not smoke but (she) is a heavy alcohol drinker.
So =the second clause expresses a result or outcome
Example: She does not smoke or drink alcohol so her health is good.
 One important decision for the writer to make is whether to include a subject in the second clause. Basically,
the rule is you need to add a subject after a conjunction if the subject of the second clause is different to that of
the first clause. Or if the sentence is very long.

Common Mistakes
Incorrect Correct
Explanation: The sentence is not balanced and there is
no
verb after the conjunction and
Explanation: No subject or verb after the conjunction
but
Explanation: Omission of subject and verb
Explanation: No subject after the conjunction and,
and note the subject for each clause is different. In
the first clause the subject is Mr Smith’s activities and
in the second clause the subject is Mr Smith (not his
activities)
Explanation: You must add a new subject here as
it is different to the subject of the first clause Her
BP Vs She
Explanation: This error is called a comma splice. A
comma splice is incorrect because two sentences
cannot be joined with a comma alone. In this case you
can join the sentences
with and.
Explanation: incomplete verb formation after and Mr. Jones has been a patient of mine since 1999 and
(he) has been attending my clinic on a regular
basis for
scaling and cleaning.

Parallel Structures & Balanced Sentences

The information in the case notes is usually written in note form, and therefore does not follow conventional
grammatical rules. However, when this information is organised into complete sentences in the referral letter it
is necessary to follow standard conventions of grammar and sentence structure. This worksheet explains how
to group information using parallel structures to ensure that the sentences you write are grammatically
balanced. This can be achieved by making sure that verbs, adjectives, nouns, prepositions, phrases and clauses
are parallel. Parallel structures within a sentence are joined with coordinating conjunctions such as and/or as
well as with commas. Here are some examples:

With active verbs

 He is now worried about his condition because he is overweight, lacks exercise and smokes regularly

With passive verbs

 During hospitalization, IV fluids were commenced and a transdermal patch was used for her pain.

With nouns & noun phrases

 He is now worried about his condition because of his increased weight, lack of exercise and his habit of
smoking.
 He will require information about how and when to take his medication, how to stop smoking and the
necessity of doing regular exercise.
 With gerunds
 In order to handle the above mentioned effects be cautious when driving a car, operating machinery or
performing any hazardous activities especially after taking your regular dose.

With prepositions
 Threadworms resemble pieces of 1.5 cm cotton thread which is normally detectable at the surface of the
feces or around the anus at night.

With verbs in the conclusion

 I am worried about Miss Jones and would appreciate your urgent assessment and treatment as you think
appropriate.

The important point to remember is that the structures must be balanced.

Common Mistakes
Incorrect Correct

 Sally initially presented alone to my clinic on
27/12/07 with a 3-month-history of
constipation and associated using laxatives
Explanation: The sentence is not balanced as
noun phrases
 He has a family history of stroke and
diabetic.
Explanation: This sentence is not balanced as
stroke is a noun and diabetic is a adjective
 Good hygiene should be maintained by
taking a morning shower, using individual
towels, washing clothes daily and to vacuum
regularly.
Explanation: the final verb is out of balance
 I am writing to refer this patient, a 26 year
old computer programmer, who is displaying
sign and symptoms consistent with subdural
haematoma.
Explanation: Both nouns should be in plural form
 His height is 170cm and weighing 99kg.
Explanation: unbalanced word form, height is
a noun, weight is a gerund
 On subsequent visits, impressions for full
upper and lower dentures were made, bite
registered and complete upper and lower
dentures were delivered.
Explanation: Passive form required for all verbs
 She diagnosed with hyperthyroidism in 1997,
hypertension in 2003 and Glaucoma since
2004.
Explanation: Time markers need to be balanced.
 Sally initially presented alone to my clinic on
27/12/07 with a 3-month-history of
constipation and associated use of laxatives
 He has a family history of stroke and diabetes
 Good hygiene should be maintained by
taking a morning shower, using individual
towels, washing clothes daily and
vacuumming regularly.
 I am writing to refer this patient, a 26 year
old computer programmer, who is displaying
signs and symptoms consistent with subdural
haematoma.
 His height is 170cm and weight is 99kg.
 On subsequent visits, impressions for full
upper and lower dentures were made, bite
registration was taken and complete upper
and lower dentures were delivered.
 She was diagnosed with hyperthyroidism in
1997, hypertension in 2003 and Glaucoma
in 2004.
 She has had hyperthyroidism since 1997,
 hypertension since 2003 and Glaucoma
since 2004.

 During hospitalization, IV fluids were  During hospitalization, IV fluids were

commenced and used a transdermal patch
for her pain.
Explanation: Passive form required for all verbs
 Further examination revealed dry mouth,
dentures were worn out on occlusal surfaces
and a heavy calculus deposit was seen on the
dentures.
Explanation: In example 1, by adding in addition,
you can change the structure and keep the
sentence balanced. In example 2 the sentence is
balanced as the verbs have been replaced with
noun phrases.
 She is feeling loneliness and isolated due to
losing her social contacts
Explanation: Loneliness is a noun whereas
isolated in an adjective so the word forms are
not balanced.
commenced and a transdermal patch was
used for her pain.
 Further examination revealed dry mouth. In
addition, her dentures were worn out on
occlusal surfaces and a heavy calculus
deposit was seen on the dentures.
 Further examination revealed dry mouth,
worn out dentures on occlusal surfaces and
heavy calculus deposits on the dentures.
 She is suffering from loneliness and
isolation due to losing her social contacts.
(nouns)
 She is feeling lonely and isolated due to
losing her social contacts. (adjectives)

Complex Sentences
Relative Clauses

In the introduction of a referral letter it is common practice to introduce the patient and provide some relevant
details relating to their situation or condition. The relative clause allows writers to do this in a clear and concise
manner.

Definition: A relative clause is the part of the sentence which provides information about the patient.They can
be divided into two types, defining and non-defining. Defining clauses provide details about the noun being
referred to. Commas are not required.
Non-defining clauses provide extra information about the noun being referred to but do not define it.Commas
are required.

Defining Non-defining
 I am writing to refer this patient who is due  I am writing to refer this patient,who is due
to be discharged today. to be discharged today, for ongoing
physiotherapy treatment.

Explanation: The relative clause defines the Explanation: The relative clause provides extra
object of the main clause i.e Which patient? The information (patient is due to be discharged)
patient who is being discharged. about the object of the main clause but does not
define it. It could be removed from the

 I am writing to refer Mrs. Patterson, a 36-
year-old married woman who is suffering
from mild depression.
Explanation: The relative clause defines the
object of the main clause i.e Who? Mrs.
Patterson, a 36-year-old woman.
n.b. In this sentence, the first comma allows extra
information to be added about Mrs. Patterson.
 Handy Tip
No name=no comma
In example 1 below, no comma is required as the relative clause is defining the person being referred to. In
example 2, the relative clause does not define the person being referred to because it is already known.
Therefore, If you include the patient's name, commas are required.
1. The doctor who performed the operation is from Iraq.
2. Doctor Yousif, who is from Iraq, performed the operation.
Incorrect
 Mr. Holmes who lives with his wife in a
government flat, is an aged care pensioner.
Explanation: Commas required as it is a non-
defining relative clause. You can also express this
information in a compound sentence.
 Mr. O'Riley, who lives alone in his own home,
and works as a fencing contractor and has only
one brother.
Explanation: After the second comma a verb is
required. i.e Mr O'Riley works..
 Mrs. Peterson who recently moved to our
retirement village following her husband's death.
Explanation: No relative pronoun needed here as
it is a simple sentence.
sentence and the meaning would still be clear: I
am writing to refer this patient for ongoing
physiotherapy treatment.
 Mrs. Patterson, who is a 36-year-old married
woman, is suffering from mild depression.
Explanation: The relative clause provides extra
information (Mrs. Patterson is a 36 year old
woman) about the subject of the main clause but
does not define it. It could be removed from the
sentence and the meaning would still be clear:
Mrs Patterson is suffering from mild depression.
Correct
 Mr. Holmes, who lives with his wife in a
government flat, is an aged care pensioner.
 Mr. Holmes lives with his wife in a
government flat and is an aged care
pensioner.
 Mr. O'Riley, who lives alone in his own home,
works as a fencing contractor and has only
one brother.
 Mrs. Peterson recently moved to our
retirement village following her husband's
death.
 Mrs. Peterson, who recently moved to our
retirement village following her husband's
death, has a history of hypertension.
 Mr. Brown presented at my clinic today with a
complaint of fractured front teeth in a traumatic
car accident.
Explanation: A relative clause is required to
define how the teeth were fractured.
Alternatively it can be written as two separate
sentences.
 I am writing regarding Mr. Jones, a 35 year-old-
male, who was recently diagnosed with with
tuberculosis.
 Mr. Brown presented at my clinic today with
a complaint of fractured front teeth which
occurred in a traumatic car accident.
 Mr. Brown presented at my clinic today with
a complaint of fractured front teeth. This
occurred in a traumatic car accident.
 I am writing regarding Mr. Jones, a 35 year-
old-male who was recently diagnosed with
with tuberculosis.

Explanation: Second comma not required as it is

a defining relative clause, i.e it defines Mr. Jones
 I am writing to refer Mrs. Margaret Green, a 66  I am writing to refer Mrs. Margaret Green, a
year old widow with three children, with 66 year old widow with three children who is
complaints of chest pain. complaining of chest pain.

Explanation: Relative clause required here as two

prepositional phrases is confusing.
 I am writing to refer, Ms. Abbot, a 58 year old  I am writing to refer Ms. Abbot, a 58 year old
widow admitted with pain, dehydration and widow who was admitted with pain,
nausea. dehydration and nausea.

Explanation: Incorrect comma placement and

relative clause required.
 Mr. Fisher was admitted to hospital with the  Mr. Fisher was admitted to hospital with the
diagnosis of obstructive artery disease and end diagnosis of obstructive artery disease which
with quadruple artery bi-pass grafts. required quadruple artery bi-pass grafts.

Explanation: A relative clause is required to

define the treatment.
 I am writing to refer this 14-year-old boy to you  I am writing to refer this 14-year-old boy
who came to me complaining of a sprained who came to me complaining of a sprained
ankle. ankle.

Explanation: The relative pronoun must follow

the noun it is referring to.
 I am writing to refer this patient, a 39 year old  I am writing to refer this patient, a 39 year
widowed woman, who is under our care after old widowed woman who is under our care
being injured in a car accident. after being injured in a car accident.

Explanation: No comma required as it is a

defining relative clause.
 Mr. Roberts who is a 72-year-old retired  Mr. Roberts, who is a 72-year-old retired
gentleman was admitted to hospital for acute gentleman, was admitted to hospital for
cerebral infarction on 08/03/10. acute cerebral infarction on 08/03/10.

Explanation: Commas required as it is a non-

defining relative clause and provides extra
information about Mr. Roberts.
 I am writing to explain Mr. Clarke's current  I am writing to explain Mr. Clarke's current
situation, who has been a patient of mine for a situation. He has been a patient of mine for a
long time. long time.
 I am writing to refer Mr. Clarke, who has
Explanation: The relative pronoun must be
been a patient of mine for a long time.
added directly after the person you are referring
Currently, he is suffering from........
to.

Clauses of Contrast

Contrast can be expressed by joining two clauses with the following linking words:
although/but/despite/despite the fact that/even though/however/in spite of/on the other
hand/whereas/while. A comma is used to separate the two clauses as illustrated below.
Although her condition has improved, she is still very weak. Her condition has improved, but she is still very
weak.
Despite an improvement in her condition, she is still very weak.
Despite the fact that there has been an improvement in her condition, she is still very weak.
Even though her condition has improved, she is still very weak. Her condition has improved. However, she is still
very weak.
Inspite of an improvement in her condition, she is still very weak
While her condition has improved, she is still very weak.

Rules for linking words

Although/Even Though + clause (underlined below)

Although + her condition has improved, she is still very weak.

Despite/Inspite of + noun or gerund (underlined below)

e.g. Despite an improvement in her condition, she is still very weak.
Despite overcoming her illness, she is still very weak

Despite the fact that/Inspite of the fact that + clause (underlined below)
e.g. Despite the fact that there has been an improvement in her condition, she is still very weak.

Despite the fact that her condition has improved, she is still very weak.

However : A comma is required after however

e.g. Her condition has improved. However, she is still very weak

Common Mistakes
Incorrect Correct

Inspite of providing with exercises and
compensatory techniques she was unable to cope
with training due to an increase in pain.
Explanation: providing is incorrect, as it was the
patient who was provided excercise, in such
cases you have 2 choices
Inspite of our provision of exercises and
compensatory techniques, she was unable to
cope with training due to an increase in pain.
Inspite of being provided with exercises and
compensatory techniques, she was unable to
 Use a noun phrase In spite of our provision of cope with training due to an increase in pain.
exercises Use passive voice In spite of being
provided with Exercise

Although she has improved, but she is still very
weak
Explanation: This sentence has two linking words
so one must be omitted.
Despite of regular follow up, plaque and tartar
were detected over cervical and bucal surfaces of
the denture teeth.
Explanation: There is no linking expression
“despite of”
Although she has improved, she is still very weak.
She has improved, but she is still very weak.
Despite regular follow up, plaque and tartar were
detected over cervical and bucal surfaces of the
denture teeth.
Inspite of regular follow up, plaque and tartar
were detected over cervical and bucal surfaces of
the denture teeth.

Despite of this advice, he regularly drinks 2~4
glasses of wine every night as well as 1~2 glasses
of scotch at weekends.
Explanation: As above
Despite this advice, he regularly drinks 2~4
glasses of wine every night as well as 1~2 glasses
of scotch at weekends.
Inspite of this advice, he regularly drinks 2~4
glasses of wine every night as well as 1~2 glasses
of scotch at
weekends.

Clauses of Purpose
Purpose clauses allow the writer to express why a certain action was taken in the past or why a certain action
needs to be taken in the future. It can be expressed by joining two clauses with the following linking words: in
order to; so that. A comma is required when the subordinate clause comes before the independent clause.

 In order to reduce weight, a low fat diet has been recommended.(quite formal and suitable for referral
letters)
 A low fat diet has been recommended in order to lose weight.
 A low fat diet has been recommended so that the patient can lose weight. (casual expression and used
more in informal writing or spoken English)

Rules
 in order to + infinitive: Further investigation is required in order to rule out bowel cancer.
 so that + past reference: A general anaesthetic was given so that the patient would not feel pain.
 so that+ future reference: A general anaesthetic needs to be given so that the patient will not feel any
pain.
 Handy Tip:

in order to rule out + disease name is a useful phrase for introductions or conclusions.

 In order to rule out ectopic pregnancy, I would appreciate your urgent assessment.
 The patient wants to have a scan for nuchal translucency in order to rule out Down's Syndrome.

Incorrect Correct
 In order for alleviation of pain, the patient  In order to alleviate of pain, the patient was
was prescribed paracetamol. prescribed paracetamol.

Explanation: In order must be followed by to +

infinitive verb, not for + noun

Clauses of Reason
In referral letters it is often necessary to state why a certain action was taken and clauses of reason allow the
writer to do this in a clear manner. It can be expressed by joining two clauses with the following linking words:
due to/due to the fact that; for this reason; because/ because of.

Examples

 Due to failure to progress and fetal stress, an emergency caesarean section was performed.
 Due to the fact that there was failure to progress and fetal stress, an emergency caesarean section was
performed. (formal)
 There was evidence of poor progress and fetal stress. For this reason, an emergency caesarean section
was performed.
 Because there was evidence of poor progress and fetal stress, an emergency caesarean section was
performed.
 Because of failure to progress and fetal stress, an emergency caesarean section was performed.

Rules
 due to/because of + noun (underlined below)

Example: Due to a low fat diet, the patient's health improved. The patient's health improved due to a low fat
diet.
Because of a low fat diet, the patient's health improved. The patient's health improved because of a low fat
diet.

 due to + gerund ( ing form)

Example: Due to losing weight, the patient's health improved.

for this reason+ clause (underlined below)
Example: The patient was placed on a low fat diet. For this reason,her health improved.
because + clause
Example: Mrs Healy's health improved because she was on a low fat diet. Because she was on a low fat diet,
Mrs Healy's health improved .

 due to the fact that + clause

Example: The patient's health improved due to the fact that she was on a low fat diet. Due to the fact that Mrs
Healy was on a low fat diet, her health improved.

 Handy Tip:
due to + ing form allows the writer to express meaning clearly and concisely so it is useful in referral letters.

Comma placement
A comma is required when the subordinate clause comes before the independent clause. However, if the
independent clause comes first, no comma is required. Click here for more details.

Incorrect
 The patient is feeling lonely and isolated due
to lose her usual social contacts.
Explanation: Incorrect word form and sentence
structure after due to
Correct
 The patient is feeling lonely and isolated due
to losing her social contacts. (clear and
concise)
 The patient is feeling lonely and isolated due
to the fact that she lost her social contacts.
(formal and a bit wordy)

 His mother had difficulty in caring for both
her son's illness and looking after two other
small children due to sick.
Explanation: Incorrect word form and sentence
structure after due to
 Recently, the Mr Hutton stopped playing
sport because muscle soreness.
Explanation: Incorrect word form and sentence
structure after because of
 His mother had difficulty in caring for both
her son's illness and looking after two other
small children due to her sickness.
 His mother had difficulty in caring for both
her son's illness and looking after two other
small children due to being sick.
 Recently, the Mr Hutton stopped playing
sport because of muscle soreness.
 Recently, the Mr Hutton stopped playing
sport because he had muscle soreness.
 Clauses of Time
A very important part of referral letters is summarising the patient history and order of events in the case notes.
The use of time conjunctions help the writer express these relationships clearly. Commonly used conjunctions
include: ago, during, when, while, since,first, on the next visit, at that time,after, later, in time etc. etc.

Example sentences

 The patient first saw me three months ago complaining of painful wisdom teeth.
 During hospitalisation, the patient had surgery to remove a suspicious lesion on his lip.
 When Mr. Matthews is discharged, he will need assistance with showering and general household
chores.
 While you are on this medication, please do not drive or consume alcohol.
 Since being admitted 3 weeks ago, the patient has steadily improved and is due to be discharged today.
 The patient first attended me yesterday evening
 On the next visit, Peter's condition had worsened and he was very anxious.
 Mr. Hauritz initially presented at my clinic on 20/11/09. At that time, examination revealed carious
lesions on several teeth along with poor dental hygiene.
 On review after three months, she had made good progress with her weight reduction.
 The patient was advised to reduce alcohol consumption, avoid heavy lifting and review in three months
time.
 A review consultation was scheduled for one month later.

Example paragraph

Six months ago, Mr. Roberts twisted his right ankle while playing golf. During the following months, the patient
experience intermittent attacks of pain which hindered his ability to work effectively. On review after three
months, the right ankle joint was x-rayed and the result appeared to be satisfactory. However, when the
swelling, pain and impaired improvement persisted, an MRI was ordered which revealed a detached
cartilage.Currently, Mr. Roberts does not have full mobility, and is no longer capable of full-time employment
on which, financially, his family depends.

Rules

 During + noun (underlined below)

Example: During his stay in hospital, Mr Mason's condition has improved.

 When + time clause (underlined below)

Example: When Ms. Song returned today, she was pale and distressed.
  While + clause (underlined below)

Example: While waiting in reception, the patient fainted.

 Ago + past tense

(underlined below) The patient had a liver transplant 12 months ago.

Comma Placement
A comma is required when the time clause comes before the independent clause.

 Handy Tip
Correct verb tense is an important point to consider when writing time clauses. The important
points to remember are as follows:

 When the verb of the time clause is in present form, the verb in the main clause must also be
present or future form.

Example: While you display symptoms of fever and rash, you are still infectious.

 When the verb of the time clause is in past form, the verb in the main clause must also be in
past form.

Example: When the patient received his results, he fainted.

 When the verb in the main clause is in present perfect form,the verb of the time clause must
be in present perfect form.

Example: While the patient has been in hospital, his condition has steadily improved.

Incorrect
 Today, the couple presented at my clinic. Mrs.
Conway informed me that her home ovulation
prediction test showed positive.
Explanation: To demonstrate a higher level of English
proficiency this information should be expressed in a
complex sentence rather than two simple sentences.
Correct
 When the couple presented at my clinic
today, Mrs. Conway informed me that her
home ovulation prediction test showed
positive.
 Today, when the couple presented at my
clinic, Mrs. Conway informed me that her
home ovulation prediction test showed
positive.
  The patient has had placement of a
prosthetic heart valve 12 months ago.
Explanation: has had is present perfect, but simple past
is required with the time marker ago.
 I first saw Mrs. Smythe at my clinic last week,
she urgently needed a new partial denture.
Explanation: An adverb of time such as when required to
connect these two independent clauses
 The patient had placement of a prosthetic
heart valve 12 months ago.
 When I first saw Mrs. Smythe at my clinic last
week , she urgently needed a new partial
denture. (best choice)
 I first saw Mrs. Smythe at my clinic last week
and she urgently needed a new partial
denture.
 Introduction to patients
Clinic
Good morning, my name is XXX, I am one of the nurses in this clinic.
What would you like me to call you?
What seems to be the troubletoday?
Ibelieve you’ve just seen your doctor.so
how are you feeling now?
what has he said?

Ward
Good morning, my name is xxx, and I’ll be looking after you today.
What would you like me to call you?
How are you doing today?

ER
Hi, my name is ***, I am one of the nurses here and will be looking after you
/your son… today.
I’m sorry I didn’t catch your name; can you tell me your name?
What brought you here today?
What are you coming here today for?
How are you feeling today?

ICU
Hi, my name is***, I am the registered nurse here and will be looking after you today.
I’m sorry I didn’t catch your name; can you tell me your name?
How are you feeling today?

School
Hi, my name is ***, I am one of the nurses in school.
And your name is?
What would you like me to call you?
How are you feeling today?

Community centre
 Hi, my name is ***, I am one of the nurses here.
How are you feeling today?
What would you like me to call you?

Shortly summaries what happened to pat after

intro
Clinic
I’ve read your records before you came in. it said that****
1. you’ve been having epilepsy since the accident last year, is that right? How have
you been feeling since then?

Ward
I’ve just read your records before coming in. it said that***
1. you’ve been having some urine tract infection after your surgery. How’re
you feeling now?
2. you’ve been having some sort of pain related to the arthritis, is that right?
3. <Procedure/examination>
You’re going to have a cardiac procedure to solve your blockage in your heart. And I
believe this is the second time to have this heart problem, is that right?
4. You’ve been having pregnancy sickness. How are you feeling now?
5. You’ve recovered well from your surgery, and about to start your chemo and
radiotherapy. Is that right?
How are feeling about it?
6. He had his tonsils removed yesterday, and he can go home today. Do you have any
concerns so far?
7. You’ve recovered well l from the stroke, and soon you can go home. How are
you feeling about it?
What have you known so far about strokes?
8. you’ve been doing well apart from some a mild would infection after your surgery. How are
you feeling about it?

ICU
1. What is your husband’s name?
2. From what I’ve known about your*** / name… so far, his condition is stable now, and he is
in good hands. Okay, don’t worry too much.
 Introductions
There are a variety of ways to write introductions and with practice you can develop a formula
that works for you. For the purpose of this document, the opening salutation and subject will be
included as part of the introduction.

Salutation : If the name of the person is included in the case notes then it should be used. This
can be followed by either a comma or full colon.

o Dear Dr. Wilson,

o Dear Dr. Wilson:

If the name of person is not mentioned then you can begin with Sir/Madam

o Dear Sir/Madam,

Subject : The subject is a place where information such as the name & age of the patient
can be included. This can save you words in the body of the letter, but be careful not include
too much information here, and definitely no phrases or sentences. Both Re & RE are
acceptable.

o Re: Dylan Charles D.O.B. 04/12/2009

o RE: Dylan Charles D.O.B. 04/12/2009

Handy Tip 1
You can save on word length by added some detail after Re, such as the patient name and
age. However, take care not to write too much here, and always use note form i.e nouns only
(no articles, verbs, adjectives)

Basically, the introductory sentence of the letter can contain the following:

1. Background Information such as name, age, occupation, marital status and

gender of the patient if relevant and not mentioned in the subject line.
2. A brief summary of the chief complaint, purpose of writing or your main concern.

It will usually be only 1 or 2 sentences long and detailed information about the patient's history
and condition should go in the main body of the letter.

Important Grammar Rules

The important patterns to learn are as follows:

Example 1
Relative Clauses: A relative clause is a useful sentence structure to use in the
introduction. It allows the write to demonstrate the ability to write a complex sentence,
which is a basic necessity to get B grade of higher.

1. I am writing to refer this patient. He is due to be discharged today. He has made a full
recovery.
2. I am writing to refer this patient who is due to be discharged today after making a full
recovery.
Example 2
Appositives: This is a noun or a noun phrase that is placed after another noun to explain or
identify it, and a comma is required to separate these nouns. It has a very important use in the
introductory sentence of referral letters as in the example below.

1. I am writing to refer Mr. Barry Booth. He is 68 years old. He is a pensioner. He is a

widower. He requires dietary advice after undergoing heart surgery.
2. I am writing to refer Mr. Barry Booth, a 68-year-old widowed pensioner who requires
dietary advice after undergoing heart surgery.

Example 3
Age : There are specific rules regarding how to refer to a patient's age. The first is that it
must be hyphenated when used before a noun such as man/woman, and the second is that an
article is required. For more details refer to Year Vs Years in the Grammar and Vocabulary
Clinic.
Incorrect Correct
 I am writing to refer this patient, a  I am writing to refer this patient, a 63-year-
63 years old man who lives alone. old man who lives alone.
 I am writing to refer this patient, 63  I am writing to refer this patient who is 63
years old man who lives alone. years old and lives alone.

Handy Tip 2
Mastery of the patterns above will ensure that you start your letter on a positive note.

Sample Introductions
Introduction Analysis
Dear Ms. Attard,  Does not include patient name as
this is clearly stated in the subject line
Re: Ms. Robyn Harwood DOB:  Uses relative clause and appositive
04/02/1948 sentence structures which
I am writing to request daily home visits by demonstrate ability to use complex
the Blue Nurses to provide care and support sentences
for this patient, a 61-year-old widow who  States purpose of writing clearly
lives on her own.

Dear Sir/Madam,  Includes shorter for a patient name

as full name stated in the subject
Re: Mr. Henry O’Keefe
line
I am writing to request aged care  Uses appositive and relative clause
assistance for Mr. O’Keefe, an sentence structure which
83-year-old man who is recovering from a demonstrates ability to use
malignant melanoma in his left shoulder. complex sentences
 States both purpose of writing and
chief complaint
Dear Sir/Madam, Re:
Mr. Bill O’ Riley
I am writing with regard to Mr. O’Riley, a 53-
year-old man who was admitted the hospital
on the 2nd of September and diagnosed with
obstructive coronary artery disease. He
underwent a coronary artery bypass graft on
the 4th of
September.
Dear Sir/Madam,
Re: Mrs. Carol Bradley
I am writing to request a respite admission
for this patient, a 41-year-old married
mother of two who has been receiving
personal care from our organisation over the
last two months.
Dear Parents:
Re: Outbreak of headlice
I am writing to inform you of a recent
outbreak of headlice at Mt Gravatt Primary
School. Although headlice spread easily and
cause several symptoms of itchiness and
discomfort, they are easy to
diagnose and treat.
Dear Mrs. MacDonald,
Re: Nasser Ali DOB:
04/02/62
I am writing to refer this patient who was
admitted to our Coronary Care Unit ten days
ago with the diagnosis of myocardial
infarction. A cardiac artery bypass graft was
done, followed by post- operative treatment
and physiotherapy. Mr. Ali’s condition has
now stabilized and he is
being discharged today.
 Includes shorter for a patient name
as full name stated in the subject
line
 Uses appositive and relative clause
sentence structure which
demonstrates ability to use
complex sentences
 Summarises chief complaint and
treatment
 Does not include patient name as this
is clearly stated in the subject line
 Includes relevant biographical detail:
age, marital status, mother
 Uses relative clause and appositive
sentence structures which
demonstrate ability to use complex
sentences
 States purpose of writing clearly and
summarises recent history
 Purpose of writing stated clearly in the
subject line
 Informs parents of main problem
 Summarises symptoms and treatment
briefly
 Does not include patient name or age
as this is clearly stated in the subject
line
 States purpose of writing clearly and
summarises recent history
 Summarises chief complaint and
treatment and current condition
 Uses relative clause structure which
demonstrate ability to use complex
sentences
Dear Dr. Thompson,  Does not include patient name or age
as this is clearly stated in the subject
Re: Ms. Amber Watson DOB:
line
25/03/1991
 States purpose of writing clearly
 Uses relative clause and
I am writing to request further testing and
appositive structures which
contraceptive advice for this patient, an 18-
year-old single woman who presented to our demonstrate ability to use
clinic for a Pap test on 16th May. complex sentences

Common Errors
Incorrect Correct
Dear Ms. Jones, Dear Ms. Jones,

Re: Mr. Adrian Lamp Re: Mr. Adrian Lamp

DOB: 10/10/1949 DOB: 10/10/1949

I am writing to refer Mr Adrian Lamp to you, I am writing to refer this patient to you, a 61-
an 61-year-old widower. He is due to be year-old widower who is due to be discharged
discharged today. He has made a full recovery today after making a full recovery from chest
from chest congestion. congestion.
Explanation: No grammatical errors, but
it lacks sophistication in the use of simple
sentences. Also, it repeats the patient name
in full which is not necessary and repetitive
since it was written directly
above in the subject line.
Dear Sir/Madam, Re: Dear Sir/Madam, Re:

Beryl Saunders Beryl Saunders

Thank you for admitting Mrs. Saunders, an Thank you for admitting Mrs. Saunders, an
80-year-old dementiapatient, requires respite 80-year-old dementia patient who requires
care for a period of two months. respite care for a period of two
Explanation: Relative pronoun required. months.
Dear Mrs. Smith,
I am writing in regards of Annette
MacNamara , single, age pensioner,
requesting your assistance when she
discharged from this hospital today.
Explanation: Several errors in terms of
sentence structure and grammar.
Dear Doctor,
Re: Mrs Diana Atherton
I am writing to refer Mrs Atherton, a 77 year I am writing to refer Mrs Atherton, a
old woman who is a resident at the Sandy
Beach Retirement Village, who needs urgent Sandy Beach Retirement Village. She needs
admission to your hospital due to chest pain. urgent admission to your hospital due to
Explanation: Incorrect sentence structure
with two relative clauses.
Dear Sir/Madam,
Re: Aiden Cooper
I am writing to refer Cooper a 12-year-old
boy, who is a year 6 student at Wellers Hill
State School.
Explanation: Two errors
1. Use first name when referring to a child.
Click here for more details.
2. Incorrect comma placement.
Dear Mrs. Smith,
I am writing in regards of Annette
MacNamara , a single age pensioner who will
require your assistance when she discharges
from hospital today.
or
I am writing to request assistance for Annette
MacNamara , a single age pensioner who is
due to be discharged from this hospital today.
Dear Sir/Madam,
Re: Mrs Diana Atherton
77-year-old woman who is a resident at the
chest pain.
or
I am writing to refer Mrs Atherton, a
77-year-old female resident at theSandy
Beach Retirement Village who needs urgent
admission to your hospital due to
chest pain.
Dear Sir/Madam,
Re: Aiden Cooper
I am writing to refer Aiden, a 12-year-old
boy who is a year 6 student at Wellers Hill State
School.
Study Strategy
When writing introductions, find a style which you like and use it for all tasks. However, take
care to understand the basic grammar rules and always remember to include the chief
complaint, purpose of writing or your main concern. Practice writing introductions using the
sample case notes provided in your course.
 Body Paragraphs

Most referral letters will contain 2 or 3 body paragraphs located between the introduction
and the conclusion. Each of the paragraphs should have a main idea which the writer needs
to convey to the reader. All the sentences with the paragraphs must relate to this main idea.
The length of the paragraphs will vary, but an approximate guideline to meet the required
word length of 180~200 words in OET is as follows:

 Introduction: 25 words
 Body paragraph 1: 40 words
 Body Paragraph 2: 40 words
 Body Paragraph 3: 70 words
 Conclusion: 25 words

Paragraph Structure
A good paragraph will contain 3 main elements

1. A Topic Sentence which introduces the reader to the main idea of the paragraph. In
many cases it will identify and/or summarise an area of concern regarding the patient.
Quite often it is written in original words rather than from words in the case notes.
2. Supporting sentences which may contain the detail regarding patient history,
descriptions of symptoms, significant aspects from the treatment record,
causes and effects, trends and so on. Quite often this information can be taken directly
from the case notes, and written as full sentences. However, you will need to
paraphrase the information into your own words. This includes:

o Changing verbs to nouns: complain=complaint

o Changing adjectives to nouns: lethargic=lethargy
o Using synonyms
o For more details on how to paraphrase, follow this link:
Paraphrase

3. Signal words link sentences together so that the information flows smoothly and is easy
to read.

Common signal words which can help you present information clearly and logically include:

a. Time: At that time, On review today, On consultation today, Recently, Over the
past 3 weeks................................................. , Two weeks later, On her next
visit, During, Since that time, Initial examination .............. , On
19/08/10...
 b. Location: During hospitalisation, Initial examination at my clinic
revealed...,On examination....
c. More information: In addition, Moreover, Also, Apart from this..
d. Contrast: However, Despite, Although
e. Result: Therefore, Consequently, As a result, For this reason...
f. Emphasis: Please note, May I remind you, My main concern is. .......................... ,
What concerns me most is.....
g. Sympathy: Unfortunately, Regrettably, Fortunately,
h. Subject: In terms of her social history..., With regard to her
medication....,Based on the blood test results. ........................ , Regarding her
medical history....., Her dental history shows. , The risk factors
include....., Treatment to date includes...
i. Advice: It is important to..., I recommend that you ..........................., Please
ensure that....
j. Chronology: Firstly, Secondly, Finally

Example 1
Case Notes Paragraphs Analysis
Diagnosis Ms. Harwood was  Topic sentence is introduced with
Right partial rotator cuff admitted to our hospital the phrase: Ms. Harwood was
tear on the 30thof October admitted to our hospital on....
Presented to Mater with a diagnosis of right  Supporting sentences
hospital with pain and rotator cuff tear transform case notes into
weakness in the right following a fall while complete sentences
shoulder, especially descending stairs.  Signal words express cause
when lifting arm Therefore, surgery has and effect and express
overhead. been suggested, contrast
Descending stairs at however, she prefers o Therefore,
home and slipped, falling non-surgical treatment. o However
onto outstretched arm. She has received
Xray and MRI showed a ibuprofen and cortisone
partial rotator cuff tear. as prescribed and also
Orthopaedic surgeon daily visits by a
discussed surgery. physiotherapist.
Patient prefers to try
non-surgical treatment.
Date of admission:
30-10-2008
Date of discharge:
01-11-2008
Treatment
Ibuprofen orally QID
Cortisone injections
Daily physiotherapy

Medical History In terms of her  Topic sentence is introduced

Diabetes Mellitus Type medical history, she with the phrase: In terms of
2 suffers from type 2 medical history,
Metformin 500mg diabetes mellitus for  Supporting sentences
mane which she is taking
transform case notes into
metformine 500mg.
complete sentences
Nursing Care Needs However, following
 Signal words connect ideas
Needs blood glucose her discharge, she will
and express contrast
level monitoring 4 need a regular
hourly monitoring on the o However,
May be elevated blood glucose level o due to
because of cortisone which may become o also
Needs assistance with elevated due to o As well as this,
shower and administration of
housework cortisone during
Orthopaedic review on hospitalisation. She
19th November will also require
assistance in
showering and home
help. As well as this,
she needs to review
her condition with an
orthopaedic surgeon
on the 19th of
November.
Social Background Ms. Harwood lives  There is no topic sentence, but the
Marital status: Widow. alone and has no main idea of social history is clear
No children. Lives children. Her next of  Supporting sentences expand the
alone kin is her niece, Megan case notes into complete
Next of kin: Megan Mack who lives in sentences, note the use of verbs,
Mack (Niece) Sydney. Regrettably,
articles and conjunctions (and)
Niece lives with she has no relatives or
 Signal word shows empathy
husband in Sydney friends to support her.
o Regrettably,
who works as software
engineer for Google
Australia. Sister died
recently. No other
relatives.
Example 2
Case Notes Paragraphs Analysis
Birth History The patient was born via  The topic sentence is begins
Normal vaginal birth at vaginal birth at term with the baby's birth.
term with a birth weight of  Supporting sentences
Birth weight: 3400gm 3400 grams. During a transform case notes into
Apgar score at 5min: 9 heatwave at Christmas, complete sentences
No antenatal or the baby became  Displays understanding of the
postnatal complications unsettled, due to lack of long case notes by summarising
fluids. When the mother the main idea. Explains
Feeding became sick for a few conflicting views of mother and
Breast fed for first three days, her mother-in-law.
weeks after birth. mother-in-law visited to  Signal words express a time
help out but has advised line, contrast and cause and
Baby became unsettled her tochange to formula effect.
during heatwave at feeds and to put more o During a heatwave
Christmas. Mother got powder in the bottle to o When...
sick and had a fever for o However,....
improve weight gain.
a few days. Mother-in- o Therefore,....
law came to visit and However, the mother
advised changing baby believes that breast milk
to formula feeds. is the best for her baby
Mother-in-law advised and would like to breast
extra powder in formula feed
feeds to improve weight
full-time but is worried
gain. Mother-in-law
says her son (Ray that she doesn’t have
Charles) also had enough breast milk for
feeding problems and the baby. Therefore, she
difficulty gaining weight has been giving extra
as a baby. formula feeds to the
baby.
Mother says she is
worried she does not
have enough breast
milk and now gives
extra formula feeds as
well as breast feeding.
She wishes she could
breast feed properly as
she believes it would be
the best thing for her
son. He hasn’t taken to
the bottle.
15/01/10 At the 6 week check-up,  Topic sentence is introduced with
the baby’s weight is the phrase: At the 6 week check
Subjective 4200 grams up,
Mother and baby and his vital signs are in  Focuses on objective
attended for routine 6 normal limits. information and final
week check-up. However, the baby is assessment.Omits less
Mother says she is suffering from mild relevant detail.
concerned about constipation,  Summarises objective details
constipation: once dehydration and concisely into "vital signs in
every three days, hard lethargy. normal limits"
stool. Mother is asking  Paraphrases adjectives into
about stool softener or nouns i.e lethargic=lethargy
prune juice for baby.

Objective
Reflexes normal
Lethargic
No abdominal
tenderness Heart
Rate: 174
Respirations: 56
Temperature: 37.1
Weight: 4200gms
3 wet nappies in last 24
hours. Urine dark.

Assessment
Mild constipation and
dehydration
Plan Could you please  Topic sentence is a request of
Increase breast feeds. support and advise the support
Refer to breast mother regarding  Supporting sentences expand
feeding support breastfeeding and case notes into formal sentences
service. Check formula correct preparation of  Signal words add cohesion
is correctly prepared. If formula feeds if o In addition,
required. In addition, o Please note,
continuing formula
advice on how to keep
feeds, advise to
the baby cool in hot
supplement with water
weather is necessary.
(boiled and cooled). Please note, the patient
Advise on keeping is due for review on
baby cool in hot 17/01/2010.
weather. Return for
review in 48
hours.
 Conclusions

The conclusion or final paragraph in the letter should be fairly standard in structure. It should
be based on the task question which is found at the end of case notes. It may contain one or
two of the following points:

 a polite request of action required

 a thank you for ongoing support
 an offer of future assistance if required (this can be useful if you choose to omit
some details from the case notes)

It is useful to be familiar with some standard patterns so that you are able to conclude your
letter confidently, quickly and most importantly, accurately. However, some degree of
originality will impress the assessors. Therefore, where possible try to ensure that your
conclusion is related to your task and not simply a memorised ending.

Important Grammar Rules

Modal Verbs : Some modal verbs & the verb hope are used to convey politeness and
commonly used for polite requests in the conclusion of formal letters. Compare the patterns
below.
Informal Polite More polite
 Can you examine  Please examine and  Could you please
and treat the patient treat the patient as examine and treat
as you feel you feel appropriate. the patient as you
appropriate  Please examine, feel appropriate
 I will be pleased if diagnose and treat  I would be grateful if
you can examine, the patient as you you could examine,
diagnose and treat feel appropriate. diagnose and treat the
the patient as you  Please arrange patient as you feel
feel appropriate. someone to help appropriate. (active)
 Can you arrange this family and  I would appreciateit if
someone to help provide proper you could examine,
this family and medical support. diagnose and treat the
provide proper patient as you feel
medical support. appropriate. (active)
 It would be greatly
appreciated if you
could examine,
Explanation: These
sentences are fine in spoken
English, but not suitable for
formal writing. Can and will
are considered less polite than
could and would.
Explanation: These diagnose and treat the
sentences are acceptablein patient as you feel
written English, but can sound appropriate. (passive
quite direct. and most polite)
 I hope you can
arrange someone to
help this family and
provide proper
medical support.

Explanation: These
sentences are the most
suitable for concluding
requests in formal letters.

Conditional Sentences: These sentences are also frequently used in the

conclusion of a referral letter and the rules are as follows:
Use a comma when the if clause is at Don’t use a comma when the if
the beginning of the sentence. clause is at the end of the sentence.
 If you could take over her on going  It would be greatly appreciated if you
care,it would be greatly appreciated. could take over her ongoing care.
 If you have any further questions  Please don’t hesitate to call me if
regarding this patient, please you have any further questions
don’t hesitate to call me. regarding this patient.

 If you require any more information,  Please don't hesitate to contact me

please don't hesitate to contact
me.(active)
 If any more information is required,
please don't hesitate to contact
me.(passive)
if you require any more
information.(active)
 Please don't hesitate to contact me
if any more information is
required.(passive)

 Should you have any further  Please don't hesitate to contact me

queries, please don't hesitate to should you have any further
contact me. queries.

Note: Sometimes if is omitted from a

conditional sentence. In full the sentence
means:
If you should have any further questions
regarding this patient, please don’t
hesitate to call me.
Closer and signature
Leave a space between the last line of the conclusion and the closer. The closer should be
followed by a comma. Then write your signature below the closer, and if you have time, print
your name below your signature.

Sample Conclusions
Case Notes Conclusion Analysis
Writing Task In order to maintain agood  Uses information
Mr O’Riley has requested health condition, Mr. from the writing
advice on low fat dietary O’Riley has requested advice task to formulate
guidelines and healthy simple on low fat dietary guidelines conclusion
recipes. Write a letter to the and healthy simple recipes. It  Contains a polite
Community Information would be greatly appreciated request
Section of the Heart if you could send the above  Maintains polite tone
Foundation, Gregory Terrace, mentioned information to Mr. through the use of
Brisbane on the patient's O’Riley at his home address, modal verbs would
behalf. Use the relevant case 9476 Old Dam Road, and could
notes to explain Mr O’Riley’s Goondiwindi, QLD, 4390.  Contains information
situation and the information specific to the task
he needs. Yours sincerely,
Include Medical History, Body Lee Wong Charge Nurse
Mass Index and lifestyle.
Information should be sent to
his home
address.
Writing Task I hope you will be able to  Uses information
Using the information in the arrange someone who can from the writing
case notes, write a letterto help this family and provide task to formulate
The Director, Community Child proper medical support. conclusion
Health Service, 15 Pauline Please do not hesitate to  Contains a request
Street, Kuraby, requesting contact me if you require using the polite
follow-up of this family. any further information expression: I hope
about this family. you will be able to..
 Contains information
Yours sincerely, specific to the task
 Offers future
Nurse assistance

Writing Task I would appreciate your  Uses information

Write a letter for the assessment and from the writing
admitting doctor of the emergency management of task to formulate
Medivale Hospital Emergency this patient’s condition. Yours conclusion
Department. Give the recent  Maintains polite
history of events and also the sincerely, tone through the
patient’s past medical history use of modal verb
and condition. Night Nurse would
Sandy Beach Retirement  Maintains level of
Village urgency appropriate
to the situation
Writing Task It would be greatly  Contains a very polite
Write a referral letter to the Dr appreciated if you could assess request using
Jane Thompson, Medical the patient's condition and conditional "if" plus
Practitioner at the North treat as you feel appropriate. passive form
Fitzroy General Practice,  Polite tone through
requesting assessment of your Yours sincerely, the use of modal
patient' condition. verbs would & could
Give the recent history of Charge Nurse  Note, sometimes a
events and also the patient’s brief conclusion is all
past medical history and that is required,
condition. or all
that you will have time
for! Although it is a
memorised phrase, it
is grammatically
correct, concise and
direct.

Discharge Plan It would be greatly  This is a long

Organise social worker and appreciated if you could do conclusion, but
Meals on Wheels. (niece will daily home visits and provide incorporates
support and reassurance for discharge plan into
visit at weekend to help with
Mrs. Butler. In addition, please
housework and shopping) the conclusion which
organize Meals on Wheels and
Stitches to be removed and is an effective strategy
a social worker for home help.
situation to be reviewed at Please note, the patient has  Emphasises a future
Out Patient Department anappointment at the Out appointment
appointment - 10.30 am 31- Patient Department at 10.30  Maintains polite
05-09 am 31-05-09 for the removal tone through the
Writing Task of stitches . Thank you for use of modal verb
Using the information in the your ongoing care. would & could
case notes, write a letterto the  Contains a polite
Director, Blue Nursing Service, Yours sincerely, thank you
207 Sydney Street, West End. Charge Nurse
 Common Errors
Incorrect
 I would very much appreciated your
attention regarding further
management of Mr. Henderson.
Explanation: Incorrect grammar, see
above
 If you have any query, please do not
hesitate to contact me.
Explanation: Use plural form of query
 I will appreciate your further
assessment and management
Explanation: Polite form "would"
required
 Kindly investigate this child and do the
needful. If you need anymore
information regarding her situation,
please try to contact me without any
hesitation.
Explanation: Several errors here. Basically it
is important that the standard patterns and
style conventions are followed in conclusions.
 Thanks to review and arrange a home
visit for this patient, if you have any
further questions, please be free to
ask me.
Explanation: As above, several errors here.
The style is casual and therefore an
inappropriate way to conclude a letter
Correct
 I would very much appreciate your
attention regarding further
management of Mr.
Henderson.(active)
 Your attention regarding further
management of Mr. Henderson
would be very much
appreciated.(passive)
 If you have any queries, please do not
hesitate to contact me.
 I would appreciate your further
assessment and management.
 I would appreciate it if you could
investigate this child’s condition and
do the necessary management. If
you require anymore information,
please do not hesitate to contact
me.
 I would appreciate it if you could
review and arrange a home visit for
this patient. If you have any further
questions, please do not hesitate to
contact me.
 It would be appreciated if you could
review and arrange a home visit for
this patient. Please do not hesitate
to contact me if youhave any further
questions.
  I would be appreciated if you could  It would be appreciated if you
take over the care of this patient. could take over the care of this
Explanation: Incorrect grammar patient. (passive verb)
 I would be appreciative if you
could take over the care of this
patient.(be + adjective)
 I would appreciate it if you could take
over the care of this patient. (active
verb)

Handy Tip
As with introductions, when writing conclusions, find a style and pattern which you are
confident with and use it. However, take care to understand the basic grammar rules and
always remember to respond to the task question. Practice writing conclusions using the
sample case notes provided in your course.