OUTPATIENT LETTER STANDARD EXAMPLE LETTERS
OUTPATIENT LETTER STANDARD EXAMPLE LETTERS
1
Contents
1 Introduction
4
1.1 Purpose of the letters
4
1.2 Audience
4
1.3 How the letters were developed
4
2 Dietetics example
5
3 Rheumatology example
7
4 Orthoptic example
9
5 Gastroenterology example
11
6 Community paediatrics example
13
7 Plastic and reconstructive surgery example
15
8 Palliative care example
17
2
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3
1 Introduction
1.1 Purpose of the letters These letters were developed as part of the Outpatient letter standard project. The purpose of the letters is to demonstrate how the headings developed can be structured in different services for different types of appointments.
1.2 Audience The letters were created primarily for the NHS digital messaging team to use in the creation of outpatient message specifications. As hospitals and GPs have different structures for their EPRs, the project has developed standards for communication of outpatient letters, ie a common standard to which local outpatient letter content can be mapped to enable the meaning to be retained when communicated to the recipient (ie semantic interoperability). The examples provided are not intended as exemplars of the way in which outpatient letters should be structured but simply to provide varied content to illustrate mapping to the PRSB standard.
1.3 How the letters were developed Clinicians from different specialties were asked to compose example outpatient letters to represent different types of appointments (initial and follow-up, doctor, and AHP led clinics) to demonstrate how the information might be best structured. The letters were quality assured by the PRSB assurance committee.
4
2 Dietetics example
Community
Nutrition
and
Dietetics
Department,
Adobe
Health
Centre,
Donaldstown,
DO1
4XP
(01234)
567890
Susan
Blight,
Community
Dietician
cndd@adobehc.nhs.uk
Patient
demographics
Attendance
details
Patient
name
Mr.
Thomas
(Tom)
Date
of
01/05/2017
Linacre
appointment/contact
Date
of
birth
01/01/1960
Contact
type
First
appointment
Gender
Male
Consultation
method
Face--to--face
NHS
number
123456789
Seen
by
Susan
Blight,
Community
dietician
Hospital
ID
TL98765
(01234)
569870
Patient
address
29
Acacia
Road
BM9
Outcome
of
patient
Appointment
to
be
made
at
a
later
6PL
attendance
date
for
follow--up
by
telephone
within
1
month.
Patient
email
thomas@
GP
Practice
details
address
Patient
telephone
077
7777
777
GP
practice
identifier
A111111
number.
GP
name
Dr
C.
O'Reilly
GP
details
Canvas
Health
Centre,
27
Acacia
Road,
BM9
6PM,
(01234)
956412
Dear
Dr.
O'Reilly,
Diagnoses:
Stroke
Problems
and
issues:
Acquired
swallowing
difficulties
I
had
the
pleasure
of
meeting
Mr.
Linacre
at
the
Community
Nutrition
and
Dietetics
outpatient
clinic
on
1
May
2017,
referred
by
Sugra
Bibi,
Hospital
dietician
at
St
Crispin's
Hospital,
Donaldstown,
DO5
7TP.
History
Mr.
Linacre
attended
the
community
nutrition
and
dietetics
outpatient
clinic
for
review
of
feeding.
Following
a
stroke
Mr.
Linacre
acquired
swallowing
difficulties.
During
a
recent
admission
to
hospital
Mr.
Linacre
was
established
on
PEG
tube
feeding.
The
feeding
tube
insitu
is
a
15French
PEG
tube
placed
05/04/17.
The
regimen
being:
1000mls
Energy
Multifibre
Feed
at
100mls/hours
for
10
hours
(9am--7pm)
with
1400mls
water
given
as
divided
flushes
(e.g.
10x140mls)
throughout
the
day
e.g.
before
and
after
feed
and
with
medications.
His
weight
is
stable.
Examinations
Weight
80kg,
Height
175cm,
BMI
26cm/2,
Clinical
summary
The
estimated
nutritional
requirements
for
Mr.
Linacre
are
Energy
1500kcla/day,
Protein
80g/day,
Fluid
2400mls/day.
Mr.
Linacre
is
tolerating
his
feed
and
fluid
flushes
well
as
per
his
feeding
regimen
and
he
reports
taking
his
medication.
Mr.
Linacre's
peg
site
has
healed
and
was
clean
and
dry
and
exposed
(no
dressing)
on
assessment.
Mr.
Linacre's
bowels
are
opening
daily
(with
no
bowel
meds),
all
pressure
areas
are
intact
and
his
weight
is
stable.
5
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