Page 50 - BUKU JILID 2 ENGLISH FOR PROFESSIONAL NURSE FIX

History of the This should include a description of the chief complaint, associated symptoms and

presenting problem relevant collateral history.
Past history Letters should include summaries of medical, surgical, and, if relevant, of obstetrical
histories.
Psychosocial history Letters should include relevant family, work and travel histories as well as habits
depending on the presenting problem.

Medications All letters should include an up- to-date medication list which includes over-the-
counter and herbal products.

Allergies All letters should list the presence (or absence ) of allergies and intolerances.
Investigations List all laboratory/imaging investigations done and indicate if any others have been
initiated even though results are not yet available.

Outline The reason for the consultation and the referring physician’s expectation(s) should
expectation(s) be clearly stated in the letter. Specific expectations regarding return of the patient
(opinion only or transfer) and the urgency of the consultation should also be stated.
adapted from: https://www.wrha.mb.ca/professionals/familyphysicians/files/APPENDIXA-Consult.pdf

Write: TRUE if the statement contradict the writer
FALSE if the statement contradict the writer
NOT GIVEN if it is impossible to say that the writer thinks about this
Example
The content of a referral’s letter needs to meet the necessity of the sender.
(T/F/NG)

1. Patient’s telephone number is needed to get additional information. (T/F/NG)
2. The past medical history of the patient should not be included in the letter. (T/F/NG)
3. Records of places visited by the patient need to be mentioned if they are
(T/F/NG)
propably related to the current problem.
4. The letter should state any foods intolerance of the patient. (T/F/NG)
5. The target specialist can do reexamination even if it has been done
(T/F/NG)
previously.
6. The preceding treatment of the doctor and the response of the patient are
(T/F/NG)
needed to help the target doctor selects more effective treatment.
7. The expected results should not be mentioned in the letter. (T/F/NG)

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