Dr.

David Booker
259 Wickham Tce
Brisbane
4001

14th August 2009 (For this date - write out in full – (numbers and word)

Dear Dr. David Booker,

Re: Mr. Darren Walker (DOB: 5/07/1969) (Numerical)

(Introduction) 2 sentences – 1st sentence social history - 2nd sentence – the purpose (This has 2
parts). Part 1 - Ask yourself….What does the patient need and why?

I am writing to refer Darren Walker, a 53 year old married man. He requires further investigations
and possibly a biopsy, as he is experiencing signs and symptoms consistent with prostate cancer.

(Body Paragraph 1) – Purpose – Part 2 - This should be an extension of the (purpose) patient’s
chief medical complaint

Today, Mr Walker attended my clinic complaining of discomfort whilst urinating. During his DRE
hardening and enlargement of his prostate was discovered/revealed/present/felt. His PSA reading
was 10. There is a family history of prostate cancer, his father was diagnosed with this condition in
2002.

With regards to Mr Walker’s medical background, he has hypertension which was initially noted
approximately 5 weeks ago, his BP was 165/90 and P80 regular. Over a period of 8 weeks he has
followed advice and reduced his BP, cut smoking to 10 cigarettes per day, started to exercise and
has lost 8 kg’s and currently weighs 77kg’s.

(Body Paragraph 3) (if required)

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Given his current symptoms (or condition), I would appreciate your management of this patient.
Additionally, could you please provide me with an update on Mr Walker’s outcome.

In the meantime, should you require any further information, please do not hesitate to contact
me.

Thank you
Yours sincerely

Dr ………………

Timeline – Symptoms – Examination/Observations – Action (advice, medications

prescribed ect) – Any other information
Dr. David Booker
259 Wickham Tce
Brisbane
4001

14th August 2009

Dear Dr. David Booker,

Re: Mr. Darren Walker (DOB: 5/07/1969)

I am writing to refer Darren Walker, a 53 year old married man. He requires further
investigations and possibly a biopsy, as he is experiencing signs and symptoms consistent
with prostate cancer.

Today, Mr Walker attended a review complaining of discomfort whilst urinating. His DRE
revealed a hardening and thickening of his prostate. His PSA test result was 10. There is a
history of prostate cancer in the family, as his father has been living with this condition
since being diagnosed in 2002 at the age of 71 years old.

With regards to this patient’s past medical history, he initially attended my clinic on the
9/07/2009 for a check-up. He was hypertensive, his BP was 165/90 and P80 regular. Due to
his BMI being high, he was advised to stop smoking and start exercising. Over a period of
approximately 7 weeks, he has lost 8kg’s and now weighs 77kg’s.

Given his current symptoms, I would appreciate your management of this patient and could
you please kindly provide me with an update on Mr Walker’s outcome.

Thank you
Yours sincerely

Dr ………………

Introduction: 2 sentences…1st social history 2nd Chief complaint and reason/purpose for
writing …What does the patient need and why?
Referral letter

I am writing to refer John Smith, a 62 year old retired lorry driver. He is experiencing signs
and symptoms consistent with gastro reflux and requires……….. (add info)

I am writing to refer Gillian Jones, a 25 year old, married office worker. She has a
preliminary diagnosis of ……… and requires ……….. (add info)

I am writing to refer Barry Jones, a 42 year old, fork-lift truck driver. He requires a work
place assessment in order to return to work following a lower back injury.

Update letter

I am writing to provide you with an update on your patient, Patricia Jameson who was
admitted to the emergency department following severe abdominal pain. She was
diagnosed with food poisoning and will require a follow-up review.

I am writing to provide an update regarding your patient, Sarah Pale who was ……… . She
will require

I am writing to provide an update on your patient George Lang. Following your referral, he
has been treated for an ectopic pregnancy and will require a review in 2 weeks’ time.

Discharge letter

I am writing to advise you that Gerald Baker following a 6 day admission for knee surgery
will be discharged today. He will require on-going care and monitoring as part of his
rehabilitation program.

I am writing to advise you that Gerald Baker will be discharged today from the Wither City
Hospital following a 5 day admission for knee replacement surgery. He will require further
care and management.

Body Paragraphs - Establishing time lines

On the 9/08/2017, Mr Jones initially attended my clinic complaining of……

Mr Jones initially attended my clinic on the 9/08/2017. He explained that for almost one
week he had been experiencing…….
On the 24/04/2018 this patient re-attended my clinic presenting with…..
Today, ……..
Two weeks later the patient returned for a review……
The patient returned 3 days later, stating that his condition has deteriorated.