OUTPATIENT LETTER STANDARD EXAMPLE LETTERS

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OUTPATIENT LETTER STANDARDEXAMPLE LETTERS1

Contents1Introduction41.1Purpose of the letters41.2Audience41.3How the letters were developed42Dietetics example53Rheumatology example74Orthoptic example95Gastroenterology example116Community paediatrics example137Plastic and reconstructive surgery example158Palliative care example172

NHS DigitalThis project was funded by NHS Digital. NHS Digital is the trusted national provider of high- ‐qualityinformation, data and IT systems for health and social care. NHS Digital collects, analyses andpublishes national data and statistical information as well as delivering national IT systems andservices to support the health and care system. The information services and products are usedextensively by a range of organisations to support the commissioning and delivery of health andcare services, and to provide information and statistics that are used to inform decision- ‐makingand choice.The Professional Record Standards BodyThe independent Professional Record Standards Body (PRSB) was registered as a CommunityInterest Company in May 2013 to oversee the further development and sustainability ofprofessional record standards. Its stated purpose in its Articles of Association is: “to ensure thatthe requirements of those who provide and receive care can be fully expressed in the structureand content of health and social care records”. Establishment of the PRSB was recommended in aDepartment of Health Information Directorate working group report in 2012.CopyrightThis document has been prepared by the Professional Record Standards Body (PRSB) on behalfof NHS Digital. You may use and re-use the information featured in this document (not includinglogos or images) free of charge in any format or medium, under the terms of the OpenGovernment Licence. Any enquiries regarding the use and re-use of this information resourceshould be sent to: enquiries@nhsdigital.nhs.uk. Where we have identified any third party copyrightmaterial you will need to obtain permission from the copyright holders concerned.Information and content NHS Digital 2017.Professional Record Standards Body32-36 Loman Street,London, SE1 0EH.www.theprsb.orgsupport@theprsb.orgCommunity Interest Company No 85408343

1 Introduction1.1 Purpose of the lettersThese letters were developed as part of the Outpatient letter standard project. The purpose ofthe letters is to demonstrate how the headings developed can be structured in differentservices for different types of appointments.1.2AudienceThe letters were created primarily for the NHS digital messaging team to use in thecreation of outpatient message specifications. As hospitals and GPs have differentstructures for their EPRs, the project has developed standards for communication ofoutpatient letters, ie a common standard to which local outpatient letter content can bemapped to enable the meaning to be retained when communicated to the recipient (iesemantic interoperability).The examples provided are not intended as exemplars of the way in which outpatientletters should be structured but simply to provide varied content to illustrate mapping tothe PRSB standard.1.3How the letters were developedClinicians from different specialties were asked to compose example outpatient letters torepresent different types of appointments (initial and follow-up, doctor, and AHP ledclinics) to demonstrate how the information might be best structured.The letters were quality assured by the PRSB assurance committee.4

2 Dietetics tFace- ‐to- Appointmenttobemadeatalaterdateforfollow- am- reintactandhisweightisstable.5

amount100mlsDosetimingPerhourfor10hoursdaily,9am- Donaldstown,DO57TP6

3 Rheumatology nceGPpracticeFirstattendanceFace- ‐to- lhistoryAlcoholintakeUnemployed10- ‐12unitsweekly7

SmokingEx- nlist:MissGently(patient),8

4 Orthoptic FirstattendanceFace- ‐to- lopiaandfresnelprism9

tient),MichaelMcMonagle,OccupationalTherapist10

5 Gastroenterology mentFace- ‐to- hhistoryofbloodydiarrhoea.Herbowelsopen5- ‐6perdaywith1- x- ‐smoker,stopped2yearsAlcoholintake:10- :Shefirstexperiencedareactionaged1211

Faecalcalproteinlevelswere247mcg/gfaeces(normal tributionlist:Ms.AgathaCritchard(patient)12

6 Community paediatrics ce(01234)567890cpc@nhs.uk01/05/2017Follow- ‐upFace- ‐to- roblemsandissues1. Tonic- ‐clonicseizures1. Increasedtonic- ‐clonicconvulsions2. Gastro- ‐oesophagealreflux2. Problemswithtransporttoschool3. Spasticquadriplegiasecondarytobirth3. Increasinglytightrighthipasphyxia4. Corticalvisualimpairment5. Bilateralconvergentsquint6. ascheduledreviewoftonic- ‐clonicseizuresandgastro- owhavingonaveragefourtonic- ticityofrighthipandmorefrequenttonic- oknownallergiesoradversereactions.Socialcontext13

fiveyearsold.Thehome- siflexto90 .Herhipsareverytight;therighthiponlyabductsto30 andthelefthipto45 atusAmendedReasonformedicationIncreasingtonic- recommendation14- mgYourssincerely14

n’sHospital7 Plastic and reconstructive surgery ionalspresentOutcomeofoutpatientattendan

4 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

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