Day to day
Referral letters
A letter built from the record — findings, medicines, laboratory values — on your own letterhead.
Press Refer on the prescription screen. The only thing you write is one line saying why you are sending them. The rest comes out of the record.
What goes in it
- The patient’s name, age, sex, blood group and allergies.
- Today’s complaints, examination and diagnosis, exactly as you wrote them.
- The medicines on today’s prescription, with their doses.
- The laboratory values outside their printed range, or that have moved a long way since last time, with the earlier figure beside them.
- How long the patient has been coming to you.
No machine writes a summary or an impression into the letter. Every line is either your own words or a laboratory’s own figure — the only safe rule for a letter somebody will act on.
Printing and keeping it
The letter prints on your letterhead like the prescription, pad mode and all. Once printed it is kept as it was — a later report does not change what last month’s letter said, because the question three months on is always "what did I send".
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