What information should be included in a written summary for a patient requesting a second opinion regarding their illness?

From the Guidelines

The written summary for a patient requesting a second opinion regarding their illness should include their diagnosis, treatment plan, medication details, prognosis, and any relevant medical history, as well as the functional impact of their condition on their daily life, according to the most recent guidelines 1. When requesting a written summary, it is essential to include key information that will facilitate a comprehensive understanding of the patient's condition and enable informed decision-making.

• The diagnosis and treatment plan should be clearly stated, including any medications, dosages, and frequency of administration.
• The patient's medical history, including any comorbidities, previous illnesses, and allergies, should be documented.
• The functional impact of the condition on the patient's daily life, such as employment, family, and social functioning, should also be included, as suggested by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
• Additionally, the written summary should include key results of recent blood tests, any newly diagnosed comorbidities, and the number of courses of oral prednisolone issued in the last 12 months, if applicable. The patient should request that their medical records be transferred to the second doctor before the appointment, and they should ask their current doctor for a referral to another specialist or find one through their insurance network.
• This process is a standard patient right protected by law, allowing patients to make informed decisions about their healthcare.
• Seeking additional medical perspectives can provide reassurance or alternative treatment options, while having written documentation helps patients better understand and manage their conditions, as supported by the guidelines for managing asthma exacerbations in the emergency department 1 and the initial evaluation and diabetes management planning 1.

From the Research

Information to be Included in a Written Summary

When a patient requests a second opinion regarding their illness, the written summary should include the following information:

• A clear and concise summary of the patient's medical history and current condition 2
• A description of the diagnosis, treatment options, and prognosis 3, 4
• An explanation of the patient's goals and preferences for their care 4
• A summary of the patient's medications, allergies, and medical tests 5
• Contact information for the patient's healthcare providers and any relevant medical records 2

Effective Communication Strategies

To ensure effective communication, the written summary should:

• Avoid using medical jargon and technical terms 3, 4
• Use clear and simple language 3
• Include illustrations or diagrams to help explain complex medical concepts 3
• Be concise and easy to understand 2
• Be provided in a timely manner, allowing the patient to review and understand the information before making decisions about their care 4, 2

Patient-Centered Care

The written summary should be patient-centered, meaning it should:

• Take into account the patient's individual needs and preferences 4
• Empower the patient to take an active role in their care 3, 2
• Provide the patient with the information they need to make informed decisions about their care 4, 2
• Be written in a way that is respectful and sensitive to the patient's concerns and feelings 3, 4