What should be included in a letter to a patient about their medical condition and treatment plan?

Writing an Effective Patient Letter: Guidelines for Medical Documentation

Patient letters should include a clear summary of the medical condition, treatment plan, and follow-up instructions, written in plain language that prioritizes the patient's understanding and ability to manage their care.

Key Components of an Effective Patient Letter

1. Structure and Format

• Use a standardized format with clear headings and consistent terminology 1
• Include four distinct sections similar to SOAP notes: patient's story (subjective), clinical findings (objective), diagnosis (assessment), and treatment plan 1
• Maintain a consistent format with standardized terminology to allow for detection of changes over time 1

2. Essential Content Elements

• Patient identification information: Full name, date of birth, medical record number
• Date of visit/hospitalization: When care was provided
• Diagnosis/medical condition: Clearly stated in understandable terms
• Treatment summary: Procedures performed, medications prescribed
• Follow-up plan: Specific timeframe for next appointment and parameters for earlier follow-up 1
• Contact information: How to reach the healthcare team with questions

3. Language and Communication Style

• Use plain, non-technical language whenever possible
• When medical terminology is necessary, provide definitions or a glossary 2
• Be empathetic and recognize that medical conditions are real and disabling 3
• Avoid judgmental language or stigmatizing terms 1

Specific Recommendations for Content

Medical Information Section

• Clearly state the diagnosis in understandable terms
• Summarize relevant test results and their significance
• Explain treatments provided and their purpose
• List current medications with dosing instructions and purpose 3
• Include a medication list with names, doses, when and how to take each medicine 3

Treatment Plan and Follow-Up

• Outline specific next steps in treatment
• Provide a specific timeframe for follow-up appointments 1
• Include parameters for when to seek earlier medical attention (e.g., "Call if you experience X, Y, or Z symptoms") 1
• List warning signs that require immediate medical attention 3
• Specify any lifestyle modifications recommended 3

Self-Management Instructions

• Include what the patient has learned about their condition 3
• Document factors that may worsen symptoms or trigger setbacks 3
• List helpful management strategies the patient has learned 3
• Identify unhelpful coping strategies to avoid 3
• Outline steps to take if symptoms worsen 3

Educational Elements

• Provide disease-specific information in clear, concise language
• Include information about medication instructions and lifestyle modifications 1
• Explain when to seek medical attention for significant changes 1
• Consider including reputable resources for additional information

Benefits of Well-Written Patient Letters

Research shows that providing patients with written summaries:

• Improves patient understanding of their medical condition and treatment 4
• Enhances self-efficacy for managing chronic conditions 5
• Reduces unnecessary emergency room visits and hospitalizations 5
• Provides a permanent record of the counseling/education provided 6

Implementation Tips

• Timing: Provide the letter at discharge or immediately following the visit
• Delivery method: Review the letter verbally with the patient before providing the written copy 4
• Follow-up: Consider a follow-up call to address any questions about the letter
• Electronic access: When possible, provide access through patient portals in addition to paper copies

Common Pitfalls to Avoid

• Information overload: Too much technical information can overwhelm patients
• Medical jargon: Unexplained technical terms reduce comprehension
• Vague instructions: Unclear follow-up plans lead to confusion
• Missing information: Incomplete medication lists or follow-up instructions
• Poor organization: Disorganized content makes it difficult to find important information

By following these guidelines, healthcare providers can create patient letters that serve as effective tools for communication, education, and improved health outcomes.