Verb Tenses

Present Perfect

Present perfect tense is used to describe an event which starts in the past and continues until the present.
Mastery of this pattern is an essential for writing successful referral letters. Three common ways to form present
perfect when writing referral letters are as follows:
Present Perfect Simple Present Perfect Progressive Present Perfect Passive
Form: have/has+ past participle Form: have/has+been+____ing Form: have/has +been+ past
(present participle) participle
 I have treated Mr. Smith at this
hospital for 3 years.  I have been treating Mr. Smith  Mr. Smith has been treated at
at this hospital for 3 years. this hospital for 3 years(..by Dr
 Dr X has treated Mr. Smith at  Dr X has been treating Mr. Smith X).
this hospital for 3 years. at this hospital for 3 years.  They have been treated at this
hospital for 3 years(..by Dr X).

Present perfect is often combined with for/since/over. Compare the usage below and note time markers used.
For Since Over
For is used to describe a period of time Since is used to refer to the start of Over uses similar time markers to for
period of time but is used to express a change in
 I have been treating the patient condition, or to describe a repeated
for 3 years.  I have been treating the patient event.
 The patient has been on this since 2007.
medication for 6 months.  The patient has been on this  The patient's condition has
 I haven’t seen the patient for 1 medication since January. deteriorated over the past 3
year.  I haven’t seen this patient since months.(change in condition)
 The patient has been in pain for December 2009.  The patient has presented
5 hours.  The patient has been in pain several times over the last year.
 The patient has been waiting for since 10am. (repeated event)
15 minutes.  The patient has been waiting  The patient's back pain has
 He has been complaining of back since 11.45am. worsened over the last
pain for a week.  He has been complaining of back week.(change in condition)
 He has not had bowel motions pain since last week.  He has tried to quit smoking
for 3 days.  He has not had bowel motions several times over the past 25
 He has been a smoker for a since Saturday. years.(repeated event)
period of 25 years.  He has been a smoker since  The patient has experienced
1985. seizures on 3 occasions over the
past year.(repeated event)

Handy Tip
When using time markers such as ...for the past 20 years, ...for the last 3months, ...for the next 3 months or .... for
the previous 3 months always use the definite article "the" as it its function is to specify a particular period of time.
 Common Errors

Incorrect Correct
 The patient was diagnosed hypothyroidism since  The patient has had hypothyroidism since
2007 2007. (present perfect)
 The patient was diagnosed with hypothyroidism in
Explanation: Past tense cannot be used with for or since 2007. (simple past)

 She has been problems with arthritis in her hands.  She has been having problems with arthritis in her
hands since 2007. (present perfect progressive)
Explanation: Problems in this sentence is a noun so you  She has had problems with arthritis in her hands
can not use “been” with a noun. You must use have or has since 2007.(present perfect simple)
+ noun or been+ ___ing verb. You can also use been +  She has been arthritic since 2007. (present perfect
adjective simple +adjective)
 She has had arthritis since 2007. (present perfect
simple +noun)

 He is smoking 2 packs of cigarettes a day for the  He has been smoking two packs of cigarettes a day
past 25 – 30 years. for the past 25-30 years. (present perfect
 Over the past week she remains free from severe progressive)
pain and has been able to tolerate a fluid diet.  Over the past week she has remained free from
 Also, there is an ulcer on the right lower lateral severe pain and has been able to tolerate a fluid
border of the tongue which is present for more than diet.(present perfect simple)
one year.  Also, there is an ulcer on the right lower lateral
  Mr. Diamond is a patient of mine since 2000 border of the tongue, which has been present for
 Mr. Eddy is a known smoker for 25-30 years. more than one year. (present perfect passive)
 Mr Diamond has been a patient of mine since
Explanation: The verbs in these sentences are in simple 2000.(present perfect simple)
present tense. Present perfect needs to be used because  Mr. Eddy has been a smoker for 25 years. (present
you are referring to a time period which started in the past perfect simple)
and has continued to the present.

 Mrs. Brown has been presenting to me on several  Mrs. Brown has presented to me on several
occasions over the past few months. occasions over the past few months.

Explanation: Progressive form not required.

Simple Past or Present Perfect

There is often confusion of whether to use simple past or present perfect tense. The basic rule to remember is if you
are referring a particular time in the past then you must use simple past tense. If you are referring to a period of time
that starts in the past and continues up to now use present perfect tense.

There are some common time markers used with simple past and present perfect. It is important to study, learn and
use these tenses correctly when writing referral letters as you must refer to both past events and periods of time
leading to the present.
Time Markers with Simple Past Time markers with Present Perfect
 He sucked his thumb until he was 5.  He has been sucking his thumb for five years.
 Mrs. Kelly had diverticulitis when she was a  Mrs. Kelly has had diverticulitis for the last 12 years.
teenager.  He has been seeing me since 2004.
 He first came to see me in 2004.  The patient hasn’t responded to treatment yet.
 The patient didn’t respond to treatment.  The patient has shown no signs of improvement up
 The patient was diagnosed with cancer 3 months to now.
ago.  The patient has stopped taking medication recently.
 The patient stopped taking medication yesterday.

Common Errors
Incorrect Correct
 She has underwent triple coronary bypass surgery  She underwent triple coronary bypass surgery on
on 10.08.09 10.08.09

Active and Passive Verb Formation

In writing a referral letter it is necessary to use a variety of verb forms including both active and passive verbs. Using
active verbs is good when you wish to create a personal tone or impart subjective information. However, passive
verbs and sentence structures enable the writer to be more objective and focus attention on what is most important
in a sentence such as the patient, procedures and treatment rather than on themselves.
Compare

1. I advised the patient to stop smoking.

2. The patient was advised to stop smoking (focus on the patient)

1. I advised her to do bed exercises to prevent further complications such as deep vein thrombosis.
2. Bed exercises were advised to prevent further complications such as deep vein thrombosis.(focus on the
treatment)

1. You need to take Flucloxacillin capsules twice a day for a duration of 2 weeks.
2. Flucloxacillin capsules need to be taken twice a day for a duration of 2 weeks.(focus on the medication)

To form the passive, use the be verb (be, is/ are; was/were; has been/have been) + past participle as described in
the table below.

Active Passive

Present simple Present simple

 The patient takes aspirin daily.  Aspirin is taken daily.

Present simple continuous Present simple continuous

 The patient is taking aspirin daily.  Aspirin is being taken daily.

Past simple Past simple

 The patient took aspirin daily.  Aspirin was taken daily.

 The patient took 3 tablets daily.  3 tablets were taken daily.

Past simple continuous Past simple continuous

 The patient was taking aspirin daily.  Aspirin was being taken daily.

Present perfect Present perfect

 The patient has taken aspirin daily for a period  Aspirin has been taken daily for a period of one
 of one year. year.

 The patient has taken aspirin, noten and  Aspirin, noten and normison have been taken

normison for a period of one year. for a period of one year.

Present perfect continuous Present perfect continuous

 The patient has been taking aspirin daily.  Nil: This form is rarely used in the passive.

Past perfect Past perfect

 The patient had taken aspirin daily for a period  Aspirin had been taken daily for a period of one

of one year. year.

 The patient had taken aspirin, noten and  Aspirin, noten and normison had been taken

normison for a period of one year. for a period of one year.

Past perfect continuous Past perfect continuous

 The patient had been taking aspirin daily.  Nil: This form is rarely used in the passive.

Future Future

 The patient will take aspirin in the evening  Aspirin will be taken in the evening.

Modal form Modal form

 The patient should have taken aspirin in the  Aspirin should have been taken in the evening.

evening.

Please review the list of common mistakes below.

Incorrect Correct
 She was performed a colostomy accompanied with a  A colostomy was performed with a partial bowel
partial bowel resection. resection.
 A colostomy was performed on the patient by the
doctor with a partial bowel resection.

The first example is better as it more concise and also it is obvious the
roles of patient and doctor so it is unnecessary to state them.
 As per the doctor’s order, we were organized daily  As per the doctor’s order, daily home visits were
home visits. organized. (passive)
 As per the doctor’s order, we organised daily home
visits. (active)

Both sentences are grammatically correct but the first example is

preferred because it focuses attention on the procedure.
 On 9.7.06 he was presented to me for his regular  On 9.7.06 he presented to me for his regular check
check up. up. (active)

Active voice is preferred here as the patient is the subject and most
likely presented himself.
 On the subsequent visit the treatment options was  On the subsequent visit the treatment options were
discussed. discussed.

Because the noun is plural the plural verb “were” is required.

 She had done colonoscopy 3 years ago.  A colonoscopy was done 3 years ago.
  She had a colonoscopy done 3 years ago.

In these sentences it is unimportant who performed the colonoscopy

so passive voice is used.
 Initially, she came to me on 14/01/2006 for a  Initially, she came to me on 14/01/2006 for a
general check up and was found her blood pressure general check up and her blood pressure was found
160/90. to be 160/90.

After the conjunction and a subject is required.

 In addition, her baby will need to monitor his growth  In addition, the baby’s growth and general health
and general health condition condition will need to be monitored

Future form of the passive.

 Noten 50mg 1/2 tablet daily was prescribed while  Noten 50mg 1/2 tablet daily was prescribed while
Zocor and Calcium Caltrate were continued taking. Zocor and Calcium Caltrate were continued to be
taken

 Today at my surgery attended Mr. Attard

 Today, Mr. Attard attended surgery
complaining of pain in his upper left molar.

complaining of pain in his upper left molar.

Use active form here as you need to focus on your patient, not your
surgery
 Past Perfect
Past Perfect is an important tense in referral letters. The main functions of this tense are:

 When used with simple past it allows the writer to distinguish the order of events:
o She had not been able to conceive over the previous four months and as a result she was suffering
from depression. This means: first she could not conceive, then she became depressed.
 When used in reported speech. The case notes may describe the patient's condition at a time in the past, i.e
patient found blood in toilet bowl 2 times. This can be written in the referral letter as follows:
o At today’s consultation, Ms. Leon reported that there had been blood in the toilet bowl on 2 occasions.

So the main benefit of using past perfect is that it allows the writer to express the order in which certain health events
occurred logically and clearly.

Handy Hint 1
Do not use past perfect when describing one past event as it is not necessary.
Compare

 The patient had been feeling unwell last week.(incorrect if 1 past event described)
 The patient was feeling unwell last week. (correct)
 The patient had been feeling unwell last week and was admitted to hospital for observation. (correct as 2
past events need to be distinguished)

Handy Hint 2
Past perfect is often used with the word previous instead of ago to demonstrate that you are referring to a time
before a particular date in the past, not the date you are writing the letter. See below for examples.
 Incorrect Correct
 She presented to me on 03/07/2010 for a regular  She presented to me on 03/07/2010 for a regular
check up because she experienced several episode check up because she had experienced several
of heart flutter over the past few weeks. episodes of heart flutter over the previous few
o Past perfect tense is necessary here (had experienced) weeks.
to differentiate what happened prior to the check up,
which is also in the past.
o As your meaning is prior to 03/07/10 and not the day of
writing the letter, you should use the word previous
instead of past.

 On review two weeks later, the frequency of  On review two weeks later, the frequency of
headache decreased. headache had decreased.
o Use past perfect to indicate that frequency of headache
had decreased prior to the consultation.

 A review on 25/04/10 showed the patient’s general  A review on 25/04/10 showed the patient’s general
health improved and her blood pressure dropped to health had improved and her blood pressure had
140/85 and she lost 4 kg. dropped to 140/85 and she had lost 4kg.
o Past perfect is used when describing a condition that
was true at a certain time in the past.

 She presented to me yesterday evening with  She presented to me yesterday evening with
abdominal pain, mostly on the left iliac fossa, and abdominal pain, mostly on the left iliac fossa, which
was since 24 hours.
 o Note that in the correct version 3 different times need had been occurring for the previous 24 hours.
to be considered
2. The present i. e today: time of writing
3. Yesterday evenings consultation
4. Symptoms which occurred before yesterday's
consultation.

 She was admitted in Royal Brisbane and Women’s  She was admitted in Royal Brisbane and Women’s
Hospital on 24/07/08 because she collapsed at Hospital on 24/07/08 because she had collapsed at
home. home.
o Use past perfect tense to create a time line, so past
perfect indicates the collapse occurred before the
admission.

 Initially she presented to me in July 2010 with a  Initially she presented to me in July 2010 with a
complaint of chest discomfort for three weeks. complaint of chest discomfort which had been
o If you use this time expression: for a few weeks then present for three weeks.
you must either use a relative clause and past perfect  Initially she presented to me in July 2006 with a
verb tense, or the very concise and useful expression: complaint of chest discomfort of 3 week duration.
of______duration.

 Mrs. Jones had taken Microgynon 30 for the previous  Mrs. Jones had taken Microgynon 30 for the previous
5 years but had stopped in May 2009. 5 years but stopped in May 2009.
o There is no need to use past perfect twice.

 On rechecking at 10.45pm, her condition has further  On rechecking at 10.45pm, her condition had further
 deteriorated and an ambulance was arranged for deteriorated and an ambulance was arranged for
transfer to hospital. transfer to hospital.
o Use past perfect and simple past together to distinguish
the order of events i.e her condition deteriorated then
an ambulance was called.

Making Subjects and Verbs Agree

This handout gives you several guidelines to help your subjects and verbs agree.

1. When the subject of a sentence is composed of two or more nouns or pronouns connected by and, use a plural verb.

She and her friends are at the fair.

2. When two or more singular nouns or pronouns are connected by or or nor, use a singular verb.

The book or the pen is in the drawer.

3. When a compound subject contains both a singular and a plural noun or pronoun joined by or or nor, the verb should agree with the part of the subject
that is nearer the verb.

The boy or his friends run every day.

His friends or the boy runs every day.
4. Doesn't is a contraction of does not and should be used only with a singular subject. Don't is a contraction of do not and should be used only with a plural
subject. The exception to this rule appears in the case of the first person and second person pronouns I and you. With these pronouns, the contraction don't
should be used.

He doesn't like it.

They don't like it.

5. Do not be misled by a phrase that comes between the subject and the verb. The verb agrees with the subject, not with a noun or pronoun in the phrase.

One of the boxes is open

The people who listen to that music are few.
The team captain, as well as his players, is anxious.
The book, including all the chapters in the first section, is boring.
The woman with all the dogs walks down my street.

6. The words each, each one, either, neither, everyone, everybody, anybody, anyone, nobody, somebody, someone, and no one are singular and require a
singular verb.
each anybody everybody
Each of these hot dogs is juicy.
each one anyone everyone
Everybody knows Mr. Jones. SINGULAR
either no one somebody
Either is correct.
niether nobody someone
7. Nouns such as civics, mathematics, dollars, measles, and news require singular verbs.

The news is on at six.

Note: the word dollars is a special case. When talking about an amount of money, it requires a singular verb, but when referring to the dollars themselves,
a plural verb is required.

Five dollars is a lot of money.

Dollars are often used instead of rubles in Russia.

8. Nouns such as scissors, tweezers, trousers, and shears require plural verbs. (There are two parts to these things.)

These scissors are dull.

Those trousers are made of wool.

9. In sentences beginning with there is or there are, the subject follows the verb. Since there is not the subject, the verb agrees with what follows.

There are many questions.

There is a question.

10. Collective nouns are words that imply more than one person but that are considered singular and take a singular verb, such as group, team, committee,
class, and family.

The team runs during practice.

The committee decides how to proceed.
The family has a long history.
My family has never been able to agree.

In some cases in American English, a sentence may call for the use of a plural verb when using a collective noun.

The crew are preparing to dock the ship.

This sentence is referring to the individual efforts of each crew member. The Gregg Reference Manual provides excellent explanations of subject-verb
agreement (section 10: 1001).

11. Expressions such as with, together with, including, accompanied by, in addition to, or as well do not change the number of the subject. If the subject is
singular, the verb is too.

The President, accompanied by his wife, is traveling to India.

All of the books, including yours, are in that box.

When the subject follows the verb

When the subject follows the verb (especially in sentences beginning with the expletives "there is" or "there are"), special care is needed to determine
the subject and to make certain that the verb agrees with it.

On the wall were several posters.

There are many possible candidates.

There is only one good candidate.

When words like "each" are the subject

When used as subjects, words such as
 each, either, neither
 another
 anyone, anybody, anything
 someone, somebody, something
 one, everyone
 everybody, everything
 no one, nobody, nothing

take singular verbs.

Do not be confused by prepositional phrases which come between a subject and its verb. They do not change the number of the subject.

Each takes her turn at rowing.

Neither likes the friends of the other.

Everyone in the fraternity has his own set of prejudices.

Each of the rowers takes her turn at rowing.

Every one of the fraternity members has his own set of prejudices.

When words like "none" are the subject

Other words such as

 none, any, all

 more, most, some
 may take either singular or plural verbs, depending on the context.

Some of the dollar was spent.

Some of the dollars were spent.

[Note: here the prepositional phrase does affect the subject. It tells you whether you are talking about a part of one thing (singular) or about a number of things (plural).]

When the subjects are joined by "and"

Subjects joined by "and" take plural verbs.

Be aware: phrases such as "in addition to," "as well as," and "along with" do not mean the same thing as "and." When inserted between the subject
and the verb, these phrases do not change the number of the subject.

Both Tom and Jane have English 167 papers due on Tuesday.

Tom, as well as Jane, has an English 207 paper due Tuesday.

When singular subjects are joined by words like "or"

Singular subjects joined by "or," "nor," "either . . . or," or "neither. . . nor" take a singular verb.

Either the man or his wife knows the truth of the matter.

Neither money nor power was important any longer.

When one subject is singular and one plural
If one subject is singular and one is plural, the verb agrees with the nearer subject.

Neither the television nor the radios work.

Neither the radios nor the television works.

When a linking verb is used

A linking verb ("is," "are," "was," "were," "seem" and others) agrees with its subject, not its complement.

Joe's favorite dessert is blueberry muffins.

Blueberry muffins are Joe's favorite dessert.

When a collective noun is used

When regarded as a unit, collective nouns, as well as noun phrases denoting quantity, take singular verbs.

The whole family is active.

(Family is a collective noun regarded as a unit.)

The family have met their various obligations.

 (The individuals of the family are regarded separately.)

A thousand bushels is a good yield.

(a quantity or unit)

A thousand bushels were crated.

(individual bushels)

When a relative pronoun is used as a subject of an adjective clause

A relative pronoun ("who," "which," or "that") used as a subject of an adjective clause takes either a singular or plural verb in order to agree with its
antecedent.

A vegetable that contains DDT can be harmful.

(Adjective clause modifying the singular noun "vegetable.")

Vegetables that contain DDT can be harmful.

(Adjective clause modifying the plural noun "vegetables.")

Mary is one of the students who have done honor to the college.

(Adjective clause modifies the plural noun "students." "Students" is the antecedent of "who."

In the above sentence Mary is just one of the students. So at least two students have done honor to the college.
 Compare that to: singular

Mary is the only one of our students who has achieved national recognition.

In this case, "one," not "students," is the antecedent of "who."

Compare to the sentence above:

Of all our students, Mary is the only one who has achieved national recognition.

Article Usage

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Articles Usage with Countable & Uncountable Nouns

Whether an article is required or not depends on the noun that follows. For this purpose nouns can be classified into two types: countable &
uncountable nouns. The difference is based on whether the noun can be counted or not. For example complaint is a countable noun as it can
be counted. Therefore it is possible to say 1 complaint or 2 complaints. Advice on the other hand cannot be counted so it is not possible to
say 1 advice or 2 advices , The correct expression is some/any advice or the expression a piece of advice.

Countable nouns
These nouns have a singular form and plural form.

Singular
In the singular form an article is usually used before the noun. Example: The doctor received a complaint from her patient.
NB. Exceptions: The article can be left out if it is replaced with another determiner such as his/her or this /that or any/each/every. E.g. The
doctor listened to each complaint. Her complaint was recorded.

Plural
In the plural form the article is usually not used before the noun. Example: The doctor received complaints from her patients.

Remember: Always use articles when referring a particular job such as:
doctor/dentist/nurse/pharmacist/physiotherapist/teacher etc etc.
Countable nouns Singular form Plural form
Note the use of an article before each noun in Note the absence of the indefinite articles a/an
singular form, either as a/an/the before each noun in singular form, but the
definite article
abscess The patient had an abscess on her gum. The patient had 3 abscesses on her gum.
ache The patient reported a dull ache in her The patient suffered from aches and pains.
abdomen.
accountant Mr. Hagen is an accountant. Mr. & Mrs. Hagen are both accountants.

appointment A follow-up appointment was scheduled. The patient did not attend her follow-up
appointments.
cavity The cavity was exposed. The cavities were exposed.
check up The patient attended for a check-up. Regular check-ups will keep you healthy.

complaint If you have a complaint, tell your doctor. If you have any complaints, tell your doctor.
condition You have a condition known as tuberculosis. There are 3 conditions which can indicate the
presence of cancer.
deposit A carious deposit was evident on tooth 32. Carious deposits were evident on teeth 32 &
33.
doctor The patient has not seen a doctor for several Three doctors were involved in the treatment
years. of the patient.
episode The patient had an episode of heart flutter. The patient reported 3 episodes of heart
flutter.
examination An examination is necessary to rule out cancer. Blood urine examinations revealed no
abnormalities.
 gum The gum surrounding tooth 23 was inflamed. The gums were infected.
increase There was an increase in the size of the The patient presented with numerous
swelling. swellings.
interpreter An interpreter is required. Interpreters will be required.
investigation An investigation is required to rule out bowel Investigations are required to rule out bowel
cancer. cancer.
limp The patient walked with a limp. All the patients had limps.
parasite The threadworm is a parasite. Threadworms are parasites.
lip The patient had a swollen lip. (one lip) The patient had swollen lips. (both lips)
smoker She is a smoker. They are smokers.
operation An operation is necessary. Two operations are necessary.
painkiller The patient requested a painkiller. Painkillers are not necessary with this
procedure.
physiotherapist An appointment needs to be a arranged with a Two physiotherapists work at this
physiotherapist. rehabilitation centre.
result The patient hoped for a positive result. The results were positive.
review A review was scheduled after 2 weeks. The nurse received positive reviews from her
patients.
sensation The patient reported a tingling sensation in his The patient experience tingling sensations in
fingers. his fingers.

social worker A social worker has been arranged to offer Two social workers have been arranged to
ongoing care. offer ongoing care.
teacher Steve is a teacher. Steve and Chris are teachers.
 test A blood test was ordered. Blood and urine tests were ordered.
visit Please organise a visit by a social worker. Regular visits by a social worker are required.

Uncountable nouns
These nouns cannot take a plural form such as: cancer, anaesthesia and information. For these words no article is required. However, the
definite article the as well as quantifiers such as some and any can be used before the noun.

Uncountable nouns Indefinite articles cannot be used with uncountable nouns.

However definite article “the” as well as quantifiers such as
some and any can be used.
accommodation The patient lives in rental accommodation.
advice Advice on diet is requested.
assistance The patient will require assistance upon discharge.
attention The patient requires urgent attention.
behaviour On examination, the patient's behaviour was abnormal.
cancer The patient has cancer.
caries Deep caries were present on several teeth.
concentration The patient has poor concentration.
damage The scan confirmed damage to the medial cartilage.
discomfort If you experience discomfort, please consult your doctor.
information Should you require further information, please do not hesitate to
contact me.
pain The patient experienced pain on palpation.
progress The patient has made good progress.
 tissue She has healthy, soft tissue.
treatment The condition did not respond to treatment.
research Further research is required.
surgery The patient chose not to have surgery.

Common mistakes
Incorrect Correct
Wound on her left knee has been stitched. A wound on her left hand has been stitched.
I am writing to refer Marvin, 7 year old boy who was admitted to I am writing to refer Marvin, a 7 year old boy who was admitted to
hospital on 21/11/10. hospital on 21/11/09.
Mr Brown has been patient of mine for 7 years. Mr Brown has been a patient of mine for 7 years.
Please note, the patient has had prosthetic heart valve for year. Please note, the patient has had a prosthetic heart valve for a year.
Examination revealed abscess on her gum. Examination revealed an abscess on her gum.
Apart from bruises to her body, X-rays reveal that she has fracture of Apart from bruises to her body, X-rays reveal that she has a fracture of
the right ankle. the right ankle.
Mr Jones had a heart surgery in 2009. Mr Jones had heart surgery in 2009.
The patient has a cancer. The patient has cancer.
She had a healthy soft tissue. She had healthy soft tissue.
He had lacerated lip and swollen gum. He had a lacerated lip and swollen gums.
The patient has pollen allergy. The patient has a pollen allergy.
The patient has tender right elbow joint. The patient has a tender right elbow joint.
The patient presented for regular check-up on 12/2/10. The patient presented for a regular check-up on 12/2/10.
 New Information Vs Previously Mentioned Information

Indefinite Article: A or An
When you mention something for the first time the indefinite article a/an is required. This signifies to the reader that
it hasn’t been mentioned before.

Definite Article: The

When you mention something for the second and subsequent times that we mention it the definite article the is
required because we are referring a something which has been mentioned before.

Example: Initially, she came to me on 03/07/06 for a blood test. The results of the blood test were negative.

Correct application of this rule creates cohesion in your letter as you are able to connect ideas, as in the example
above, where the reader knows which blood test is being referred. Conversely, incorrect use can confuse the reader.

Example: Initially, she came to me on 03/07/06 for the blood test. The results of a blood test were negative.

In the example above the ideas are not connected and the reader will be confused.
Incorrect Correct
 The patient has the family history of diabetes.  The patient has a family history of diabetes.

Explanation: If it is the first time to give this information

then the indefinite article is required for countable nouns.
 In addition, the pain in the right knee joint has  In addition, pain in the right knee joint has appeared
appeared over the last 2 days. over the last 2 days.
  Thank you for seeing, Mr and Mrs Conway, who have  Thank you for seeing, Mr and Mrs Conway, who have
presented to me for the fertility advice. presented to me for fertility advice.

Explanation: If it is the first time to give this information

and the word is an uncountable noun, such as pain or
advice, then no article is required. Note, this error has a
big effect on meaning: the in this case implies that this
subject has been mentioned previously, which of course it
hasn't.
For more details on countable & uncountable nouns click here
 Thank you for seeing this patient, an eight year old  Thank you for seeing this patient ,an eight year old
girl who presented today with the broken left arm girl who presented today with a broken left arm
following the accident at her school play ground.It following an accident at her school play ground.It
has been forty minutes since a accident. has been forty minutes since the accident.

Referring to Something Specific

The definite article is used when referring to something specific. It is very important to include this article to signify
the information is specific.

Note: These articles are usually omitted in the case notes. This is because the case notes are in short note form and
standard grammar rules do not apply. However for referral letters it is necessary to apply and adhere to standard
grammar rules.

Incorrect Correct
 She was on Microgynon 30 for previous 5 years.  She was on Microgynon 30 for the previous 5 years
 He has been a smoker for last 12 years.  He has been a smoker for the last 12 years.
 Mr. Roberts has been a resident at our nursing home  Mr. Roberts has been a resident at our nursing home
for past 2 years. for the past 2 years.
 This medication needs to be taken twice a day for  This medication needs to be taken twice a day for
next 3 days. the next 3 days.

Explanation: All the expressions above are referring to a

specific period of time so a definite article is required.
 Mrs Sangean is currently on following medication:  Mrs Sangean is currently on the following
karvea 150mg daily, oroxinen 0.1 daily. medication: karvea 150mg daily, oroxinen 0.1 daily

Explanation:In this case, the writer is referring to specific

medication. i.e that which follows.
 The patient reported pain in left ankle.  The patient reported pain in the left ankle.

Explanation: Here the writer is referring to a specific side,

i.e not the right side but the left side.
 Patient complained of chest pain.  The patient complained of chest pain.

Explanation: Patient requires an article to indicate which

patient the writer is referring to.
 Examination revealed a slightly swollen joint and a  Examination revealed a slightly swollen joint and a
tender spot on medial aspect of it. tender spot on the medial aspect of it.

Explanation: Here the writer is referring to a specific

region, i.e not the anterior aspect but the medial aspect.

 Based on above information, I believe the patient  Based on the above information, I believe the
needs urgent admission to hospital. patient needs urgent admission to hospital.

Explanation: Here the writer is referring to a specific

information, i.e not the information on the medical chart
but the information written above.
 Thank you for seeing this patient who presented at  Thank you for seeing this patient who presented at
my surgery regarding tooth 54 which has been my surgery regarding tooth 54 which has been
temporary filled by school dental service. temporary filled by the school dental service.

Explanation: Here the writer is referring to a specific

dental service, i.e not the community dental service but
the school dental service.

Special Usage of Articles

There are some situations where you should always use the definite article and there are some situations where the
indefinite article is required. Understanding these rules can greatly reduce the number of "minor" errors in your
writing so please study these rules carefully.

Handy Hint!
Articles are usually omitted in the case notes. This is because the case notes are in short note form and standard
grammar rules do not apply. However for referral letters it is necessary to apply and adhere to standard grammar
rules including article usage.

Body Parts

The definite article "the" should be used when referring to parts of the body.
Incorrect Correct
 Pain in left groin.  Pain in the left groin.
 Pain in stomach.  Pain in the stomach.
 I suspect it to be adenoma of parotid gland.  I suspect it to be adenoma of the parotid gland.
 Mr. Smith had an operation on a left knee.  Mr. Smith had an operation on the left knee.

Names of Diseases
Do not use an article for names of diseases or conditions.
Incorrect Correct
 The patient is suffering from the high blood  The patient is suffering from high blood pressure.
pressure.  Recently, the patient has complained of headache.
 Recently, the patient has complained of the  The patient was diagnosed with arthritis.
 headache.  The patient has had influenza for three days.
 The patient was diagnosed with the arthritis.
 The patient has had the influenza for three days.

Same
Always use the definite article with this word.
Incorrect Correct
 She has a family history of same disease that had  She has a family history of the same disease that
been controlled by Risperidone. had been controlled by Risperidone.
 The children were treated by same dentist.  The children were treated by the same dentist.
 The medication is same as last time.  The medication is the same as last time.

Articles with Gerunds

A gerund is the …ing form of a verb which takes on the grammatical function of a noun. It can be the subject or object
in a sentence. Usually no article is required with gerunds.
Incorrect Correct
 On review today, Mr Walker has reduced the  On review today, Mr Walker has reduced smoking
smoking from 20 to 10 cigarettes per day. from 20 to 10 cigarettes per day.
 The patient was advised to stop the drinking.  The patient was advised to stop drinking.
 Articles and Nominalisation
Nominalisation is a process where verbs can be turned into a "noun phrase". For example:The patient sucked his
thumb until he was five becomes The patient had a habit of thumb sucking until the age of five.

Often in medical English, it is necessary to use nominalisation such as: The excessive drinking of alcohol will adversely
affect your health. The reduction of weight has led to improved health. It is common in these cases to use an article
before the nominalised expression.

The other benefit of using the style of writing is that it creates a formal tone and allows you to summarise details from
the case notes.

Incorrect Correct
 The patient is complaining of discomfort during  The patient is complaining of discomfort during the
passing of urine. passing of urine.

Appropriateness of Language

Informal & Casual Expressions

The written language of English is different to the spoken language in that it is quite formal whereas the spoken form
is more casual. If spoken language expressions are used in formal letters it affects the “tone and register” of the letter.
Therefore, it is important to maintain a formal tone and use standard expressions. Below is a list of inappropriate
casual expressions with more formal appropriate expressions.

Example Words

Casual Formal Casual Formal Casual Formal Casual Formal Casual Formal Casual Formal
asks for requests think believe get became so very but however kids children
say state get receive got become about regarding really greatly sad depressed
said stated got received So Therefore a bit slightly kid child till until
like include like such as don't do not Thanks Thank-you kids children lots a lot of

Example Sentences

Inappropriate Casual or Spoken Expression Appropriate Formal Expression

 She refuses to eat solids and prefers fluids only like  She refuses to eat solids and prefers fluids such as
apple juice and lemonade. apple juice and lemonade.
 There are several measures which can be taken to  There are several measures which can be taken to
reduce the risk of infection like taking a shower in reduce the risk of infection including taking a shower
morning, using separate towel for everyone, in morning, using separate towel for everyone,
changing underwear and bed sheets regularly, changing underwear and bed sheets regularly,
vacuuming carpets, keeping the nails short and vacuuming carpets, keeping the nails short and
 washing hand thoroughly. washing hand thoroughly.
 She was given general advise for softening her  She was given her general advise for softening her
stool,like changing her dietary habit but she was non stool such as changing her dietary habit but she was
compliant. non compliant.

Explanation: Like is a casual expression, and the two

commonly used formal expressions with the same
meaning are such as & including.
 Thanks for seeing Mr. Brown.  Thank you for seeing Mr. Brown.
 Thanks for arranging a home visit for this patient. If  Thank you for arranging a home visit for this patient.
you have any further questions, please feel free to If you have any further questions, please be free to
ask me. ask me.

Explanation: Thanks is a casual expression and should be

written in full.
 In view of the above signs and symptoms I think she  In view of the above signs and symptoms I believe
is suffering from schizophrenia. she is suffering from schizophrenia
 The patient's family is thinking about a reduction in  The patient's family is considering a reduction in her
her medication. medication.

Explanation: think is informal and preferable expression is

either believe or consider, depending on the context.
 I would really appreciate your attention regarding  I would very much appreciate your attention
further management of this patient. regarding further management of this patient.
 I would greatly appreciate your attention regarding
Explanation: Really is spoken language and should be
avoided in formal writing. further management of this patient.

 About his dietary habits, he eats a large amount of  Regarding his dietary habits, he eats a large amount
oily and sweet food. of oily and sweet food.
 If you require any other information about her  If you require any other information regarding her
condition, please do not hesitate to contact me. condition, please do not hesitate to contact me.

Explanation: About is a casual expression, regarding is

more suitable. Lots of is also casual. “A large amount of” is
more formal.
 She had lots of pain.  She had a lot of pain.
 He eats lots of oily food.  He eats large amounts of oily food.

Explanation:Lots is a spoken expression

 There was nothing significant in his social history.  There were no significant findings in his social
history.
Explanation: Nothing is more commonly a spoken
expression which is not suitable for writing.
 Please do not hesitate to contact me if u need  Please do not hesitate to contact me if you need
additional information. additional information.

Explanation: Definitely no text or SMS language in formal

letters. Replace with: you
 She has got maternal postpartum haemorrhage of  She has had maternal postpartum haemorrhage of
800mls. 800mls.
 Mr O’ Riley got an appointment for a follow up visit  Mr O’ Riley has an appointment for a follow up visit
 with his general practitioner, Dr. Avril Jensen. with his general practitioner, Dr. Avril Jensen.
 The mother got sick for a few days.  The mother became sick for a few days

Explanation: Got/Get are casual expressions and should

generally be avoided in formal letters.
 Should you have any concerns regarding them,  Should you have any concerns regarding Mary and
please do not hesitate to contact me. her child, please do not hesitate to contact me.

Explanation: The pronoun them sounds casual here. It is

much better to use the patient’s name, especially in the
final sentence of the letter.

 At the moment, she is weak and disorientated  At the moment, she is weak and disorientated at
sometimes but severe pain has been alleviated. times but severe pain has been alleviated.
 At the moment, she is weak and disorientated on
Explanation: Sometimes is a casual expression. More occasions but severe pain has been alleviated.
formal expressions include: at times or on occasions
 This pain was exaggerated to cold and hot things  This pain was exaggerated to hot and cold stimuli.

Explanation: Things is a casual expression and should be

avoided
 A repeat vaginal examination revealed a very tender  A repeat vaginal examination revealed a very tender
right vaginal fornix. But her blood pressure pulse is right vaginal fornix. However, her blood pressure
within normal range. pulse is within normal range.

Explanation: It is not good English to begin a sentence

with the conjunction but In this case use However, as it is
more formal
 Her temperature and blood pressure were normal  Her temperature and blood pressure were normal
while pulse was elevated at 88. So I recommended while pulse was elevated at 88. Therefore, I
that she return today for a blood test and recommended that she return today for a blood test
reassessment. and reassessment.

Explanation: So is a casual word, you can use it within a

sentence, but not to start a sentence in formal writing. Replace
with: Therefore,
 There was evidence of poor oral hygiene, carious  There was evidence of poor oral hygiene, carious
lesions and active periodontal disease too. lesions and active periodontal disease as well.

Explanation: too is informal, a more more formal

expression is as well.
 Her husband was upset because, she was not  Her husband was upset because, she was not
showing interest towards the kids. showing interest towards the children.
 Mark's dad also suffers from this condition.  Mark's father also suffers from this condition.
 The teacher spoke to her mum regarding the regular  The teacher spoke to her mother regarding the
absences from school. regular absences from school.

Explanation: kids, dad, mum are all spoken expressions

which are inappropriate in formal letters.
 She had had termination of pregnancy 10 years  She had had termination of pregnancy 10 years ago.
back.  He is a regular smoker and drinker with the only
 He is a regular smoker and drinker with the only relevant past history of left inguinal hernia operation
 relevant past history of left inguinal hernia operation 2 years previously.
2 years back.

Explanation: Back is used as a spoken expression not a

written expression.
 He had a habit of thumb sucking till the age of 5.  He had a habit of thumb sucking until the age of 5.

Explanation: Till is casual, until is formal

 She was so anxious.  She was very anxious.

Explanation: So is informal and subjective, whereas very

is more formal and objective.
 Owen has big tonsils.  Owen has enlarged tonsils

Explanation: big is informal and does not sound

professional.
 I am writing to request a follow-up for this patient.  I am writing to request a follow-up visit for this
 Examination revealed that his vitals were stable and patient.
left knee was swollen without effusion.  Examination revealed that his vital signs were stable
 Examination revealed normal vitals. and left knee was swollen without effusion.
 Examination revealed that his vital signs were
Explanation: Vitals and follow up are incomplete normal.
expressions, commonly used in spoken English, but not
suitable for formal writing.
 Mrs. Jones is a widow who complained of persistent  Mrs. Jones is a widow who complained of persistent
chest pain at roughly 1.45pm. chest pain at approximately 1.45pm.
  Miss Roberts started smoking around 6 months ago.  Miss Roberts started smoking approximately 6
months ago.
Roughly and around are casual or vague expressions.
 I recommend some investigations to rule out cancer.  I recommend further investigations to rule out
 I requested some blood tests. cancer.
 I requested additional blood tests.
Explanation: Some is vague and does not sound
professional.
 Her BMI was 28 and all the rest of the examinations  Her BMI was 28 and the remainder of the
were normal. examinations were normal.

Explanation: all the rest of sounds informal.

 Abdominal examination revealed a small right groin  Abdominal examination revealed a small right groin
swelling that’s consistent with inguinal hernia. swelling that is consistent with inguinal hernia.
 Thank you for your expert care and please don't  Thank you for your expert care and please do not
hesitate to contact us if you require further hesitate to contact us if you require further
information. information.

Explanation: It is best to avoid contractions in formal

letters as these are used more in spoken English.
 In addition, she is just able to tolerate fluids.  In addition, she is only able to tolerate fluids.

Explanation:Just can sound informal at times.

 Medical Terminology
The medical case notes for the OET exam often contain abbreviations, medical acronyms and technical language. The
task for the writer is to expand these into full words and sentences. There are 3 reasons why this is important.

1. As the OET is a test of English, you need to demonstrate your ability to transfer technical language in the
case notes into standard English.
2. For some letters you are may have to write to someone who is not a health professional such as a social
worker or family member.
3. A referral letter is not a report so the standard conventions of letter writing require a formal style which
includes using complete words and sentences.

Handy Hint: It is a test of English not Latin, so where possible avoid the use of Latin based acronyms
and words.

Here is a list of common abbreviations used in Australia.

Acronym/Short Form Full Expression Acronym/Short Form Full Expression
Abdo Abdomen mane in the morning
AC before meals min minute
ADL activities of daily living NAD no abnormality detected
& and nocte in the evening
BD/bid 2 times a day OPG orthopantomogram
BP blood pressure P/PR Pulse/Pulse Rate
BW x-rays bite wing x-rays PMH past medical history
C/O complains of PRN as required
cap capsule QID 4 times a day
DOB Date of Birth R right
ECG electrocardiograph tab tablet
F/- fluoride application sid once a day
FBC full Blood Count TDS/tid 3 times a day
FTA failed to Attend w/o without
IV intravenous y/yrs year
h hour ? rheumatic fever possibility of something
hx history 6/h 6 hourly
L left + positive
lab laboratory 3/12 3 months

Exceptions to this rule include abbreviations of measurement. Therefore it is acceptable to use the
following in short form:
Acronym/Short Form Full Expression Acronym/Short Form Full Expression
cm centimeter ml millilitre
g gram mg milligram
kg kilogram mm hg milligram of mercury

Common Errors
Incorrect Correct
 Her current medications include sid Metformin 500  Her current medications include a daily dose of
 mg. mane and nocte, Glycosamine 5mg.mane and Metformin 500 mg. in the morning and at night,
Candesartan 10mg. nocte. Glycosamine 5mg.in the morning and Candesartan
10mg. at night.

 After discharge from hospital, Mrs.Jones has been  After discharge from hospital, Mrs.Jones has been
told to take Aperients (PRN) and Aldomet (250 mg told to take Aperients when required and Aldomet
bid). twice a day.

 I treated Claudia with prednisolone5mg 1t/sid for  I treated Claudia with prednisolone 5mg tablet once
seven days. a day for seven days.

 On examination, there was tenderness and rebound  On examination, there was tenderness and rebound
tenderness over the R. iliac fossa. tenderness over the right
iliac fossa.

 I am writing to refer Mrs. Wilson, a 45yr old woman  I am writing to refer Mrs. Wilson, a 45-year-old
who is suffering from signs and symptoms woman who is suffering from signs and symptoms
suggestive of advanced English. suggestive of advanced English.

 She presented to me yesterday evening with  She presented to me yesterday evening with
abdominal pain mostly in the left iliac fossa which abdominal pain mostly in the left iliac fossa which
had been present for the last 24 hrs. had been present for the last 24 hours.

 Her mother died of MI  Her mother died of myocardial infarction

  On examination she was found to have PR 88/min  On examination she was found to have a pulse rate
of 88 beats per minute.
 On examination she was found to have a pulse of 88.

 Mr Duane Eddy 57/m is an a urgent referral  Mr Duane Eddy, a 57 year old male is an a urgent
regarding an ulcer in R. lateral border of tongue. referral regarding an ulcer in the right lateral border
of tongue

 I would appreciate if you could inform me about her  I would appreciate if you could inform me about her
treatment & progress over the next few days. treatment and progress over the next few days.

 The patient was discharged on Dec. 30 2009.  The patient was discharged on December 30 2009.
 The patient was discharged on 30/12/09.

 Lab work and review was planned for the next  Laboratory work and review was planned for the
morning. next morning.

Referring to a Patient
There are certain conventions which need to be followed when referring to a patient in a formal letter. This worksheet
will explain what you need to know so that you can conform to these conventions.

The basic rules regarding titles are as follows:

 Mr. is used for adult men, married or single

  Mrs. is used for married women including widows
 Ms. is used to refer to both married or unmarried women
 Miss is used for young girls or unmarried women
 Master is used for young boys, but is rare nowadays as it has become old fashioned. It is still commonly used
on an envelope, but not in the body of the letter.
nb Both miss & master are not abbreviations so no punctuation is required.

Handy Tip 1: Definitely do not use titles with first names only, i.e Mr Thomas or Mrs. Carol as this is not acceptable.
See below for correct usage.

These titles can be used in the following ways

 I am writing to refer Mr. Hacker (standard)

 I am writing to refer Mr. Thomas Hacker (very formal, usually used above the address or after Re: but not
on the body of the letter.)
 I am writing to refer Thomas (informal and commonly used for children)
 I am writing to refer this patient (commonly used in the opening sentence if patient's name has been
mentioned above as in Re: Mr. Thomas Hacker)

Question: When and how often should I use the patient's name in the letter?
Answer: The standard way is to write the patient's name in full below the opening saluation. Then, use the patient's
name once per paragraph as illustrated below, after which you can use pronouns. Also, be consistent in how you refer
to the patient. Do not mix up your use of first names and surnames in the letter as this will only confuse the reader.

Handy Tip 2: There is no need to write the patient's name out in full in the introduction if you have stated it below
the salutation i.e Re: Mrs. Carol Brady as it is very clear who you are writing about. In such cases use "this patient"
or title and surname "Mrs. Brady". If you do this you will be following standard conventions.

Example Letter

31 July 2009

The Director
Redeemer Palliative Care Hospital
32 Nelson Drive
St Lucia
Queensland, 4050

Dear Sir/Madam,

Re: Mrs. Carol Brady

DOB 4 February 1968

I am writing to refer this patient, a 42 year old married woman who was diagnosed with stage 4 ovarian cancer on 22
May 2009. I would appreciate it if you could provide respite care for her.

I have been supporting Mrs. Brady and her family for the past 2 months,and she is on palliative care and now only
expected to live for four months. Her husband Mr. Mike Brady is her primary carer,and he has reduced his work hours
to look after her and their children aged 10 and 12. He usually feels that he is exhausted, emotionally stressed and
isolated because he finds it difficult to cope with all the work at home.

Mrs. Brady is depressed and withdrawn and she does want any visitors. In addition, she has not been eating much
recently. Regarding medication, she takes oxycontin and stemitel twice daily and is on a regular panadol. However,
her pain is still increasing.

Could you please do a reassessment of Mrs. Brady’s pain medication as it may need to be increased. Thank you for
looking after this patient and please do not hesitate to contact me if you have any further questions.

Yours sincerely,

Community Nurse

Common Mistakes
Mr. Langer is an only child. Alfie is an only child.
Explanation: Mr. is only used for adult men, so if the
patient is a child you should use their first name.
Thank you for seeing my patient, Master Alfie Langer, a 7 Thank you for seeing my patient, Alfie Langer, a 7 year old
year old boy. boy.
Explanation: Master is somewhat old fashioned and does
not sound "familiar" if used in the body of the letter.
Mr. Peter, a 23 year old young man, presented at my Mr Holmes, a 23 year old young man, presented at my
surgery today complaining of painful wisdom teeth. surgery today complaining of painful wisdom teeth.
Explanation: You can not use titles with first names only.
I am writing to refer Miss. Green for surgical assessment. I am writing to refer Miss Green for surgical assessment.
Explanation: Miss is not an abbreviation so no punctuation
required.
Dear Dr., Dear Doctor,
I am writing this letter.... I am writing this letter....
Explanation: Do not use short forms without the surname
of the person.

Control of Presentation Features

Letter Format

One of the criteria used to assess your writing in the OET exam is Control of Presentation Features. This criterion
assesses the overall presentation of the letter and includes a lot of the features outside the body of the letter including

 Letter format
 Punctuation
  Capital letters
 Spelling

This worksheet will describe the characteristics of formal medical correspondence. To do this, the letter has been
broken up into 6 parts.

1. Date: The date should be placed at either the top left or top right of the letter and can be either written in full or
as numbers as follows:

o 21/07/10
o July 21, 2010
o 21st July, 2010

2. Address: The address gives the name and address of the person or facility to whom you are writing. There are
some basic conventions which need to be followed including:

o Capital letters for job titles, names & street names

o Commas not required when the address in separated by lines

Dr. John Howard Dr Ian Hanson Lactation Consultant

1 Wickham Tce Consultant Orthopaedic Surgeon Breast Feeding Support Centre
Spring Hill Riverlea Public Hospital 68 Main Street
QLD 4010 Graham Street Romaville
Riverlea N.S.W 2068
3.Salutation: If the name of the person is included in the case notes then it should be used. This can be followed by
either a comma or full colon.

o Dear Dr. Wilson,

o Dear Dr. Wilson:

If the name of person is not mentioned and they are a non-medical person, then you can begin with Sir/Madam as
used in business correspondence or if they are a medical professional you can use their job title Doctor/Nurse/Dentist
etc

o Dear Sir/Madam,
o Dear Doctor
o Dear Nurse

4.Subject: The subject is a place where information such as the name & age of the patient can be included. This can
save you words in the body of the letter, but be careful not include too much information here, and definitely no
phrases or sentences. Both Re & RE are acceptable.

o Re: Dylan Charles D.O.B.04/12/2010

o RE: Dylan Charles D.O.B.04/12/2010

5.Body: The information in the body of the letter should be divided into paragraphs, with the standard format for a
referral letter being as follows:
 o Introduction which includes background information & purpose of writing or chief complaint in
summary form.
o Past medical/social history
o Current condition in detail or discharge plan
o Conclusion, which if time permits, should be specific to the scenario in then case notes.

Note: OET requires the letters to be between 180~200 words approximately. The word length is based on the body
of the letter only.

6.Closer: The closer is the final part of the letter and should be written one space below the last line of the body. Only
the first word in the closer should be capitalised and a comma should following the last word.

o Yours sincerely,(standard)
o Sincerely yours,
o Sincerely,
o Yours truly, (American style, but gaining popularity in Australia)
o With best regards,

Note: Yours faithfully, is often recommended as a closer when you don't know the name of the person to whom you
are writing. However, in formal medical correspondence it is not advised as it puts you in a subservient position.

Sample Letter Format from a Physiotherapist

05/02/2010

Mr. Alex Hinges

Southside Physiotherapy Centre
15 Kings Street
New Hampshire
N.S.W 2240

Dear Mr. Hinges,

Re: Master Peter MacLean
D.O.B. 17/10/1993

Thank you for taking over the care of Peter, a 17-year-old student who has a history of cystic fibrosis
(CF).

Peter was diagnosed with CF when he was born and he needs frequent admissions due to recurrent lung
infections. He lives with his parents and an elder brother. Peter currently takes Pancrease, omeprazole
and oral hypoglycaemics. His self-management program includes active cycle breathing (ACB), positive
expiratory pressure (PEP), flutter and posture drainage (PD). Peter’s fitness is maintained by biking
to school.

He was admitted with an exacerbation of his CF on 02/02/2010 with frequent small and non-productive
coughs. Examination revealed a thin and moderate dehydrated young man with hyperinflated chest. His
temperature was spiking. He had moderately decreased lung function with blood oxygen saturation (SaO2)
of 95%. There were widespread crackles on auscultation. Peter was treated with antibiotics intravenously.

Initial physiotherapy consisted of PD, percussion and vibration. Effective cough techniques were
demonstrated.

Peter’s condition has improved and he started gym sessions today. I have arranged for an appointment
with Peter to check the effect of car fumes when he is biking. I will consider a mask to keep his
airway moisturised if the car fumes impact on his breathing.

Peter will be discharged in 3 days from the medical ward and will require on going care.

Yours sincerely,

Tania Robinson
Physiotherapist

Common Errors
Incorrect Correct
30 Dec. 09 30 December 2009
Explanation: The date should be written in full. 30/12/09
To Dr. Blair Howell
Dr. Blair Howell, Admitting Doctor
Admitting doctor 28 George Street
28, George street, Spring Hill
Spring hill, Queensland 4000
Queensland 4000

Explanation:

1. To not required.
2. Commas not required when the address is written
top at the letter because the information is
separated lines.
 3. Capitals required for job titles
4. Capitals required for street names & suburbs.

Dear Dr Jones Dear Dr. Jones,

Explanation: Comma or full colon required Dear Dr. Jones:
Re: Julie Crosby, 25 yr receptionist, single Re: Julie Crosby, 25 years of age
Explanation: Too much information. Best practice is too Re: Julie Crosby, D.O.B 21/07/85
include name and age of patient only. Other information
such as gender, profession, marital status and so forth can
be included in the opening sentence.
Your's sincerely, Yours sincerely,
Explanation: The possessive form is used before nouns,
not adverbs
Regards, With best regards,
Mary Smith Mary Smith
Charge Nurse Charge Nurse
Explanation: Informal, email style closer
Thanks, Thank you for your assistance regarding this patient.
Mary Smith
Charge Nurse Yours sincerely,
Explanation: Too casual Mary Smith
Charge Nurse
Hello Dr. Jones, Dear Dr. Jones
Hi Dr. Jones
Explanation: Too casual
 The Comma
The comma is the most frequently used punctuation mark within sentences. Used correctly it allows the writer to
separate a group of words or phrase from other parts of a sentence. This is necessary in order to add useful
information in a sentence. The information can be added at the beginning, the middle or the end. However if commas
are not used or overused, the meaning can be affected and the flow of information disrupted. By understanding the
basic rules presented in this section you should be able to develop a good understanding of how and when to use
commas in referral letters.

Rules of Usage

1. The Adverbial Phrase: The adverbial phrase can be used in referral letters to provide information such as a time,
place, context, emphasis or mood in the sentence which is to follow and it is commonly separated by a comma

o Context: On examination, there was slight tenderness in the right fornix.

o Date: On today’s visit, the patient was pale and sweaty.
o Emphasis: Please note, the patient is allergic to penicillin.
o Mood: Unfortunately, the patient’s condition has worsened. Note, mood or comment adverbs, such as
unfortunately or regrettably convey the health professionals concern toward the patient’s condition
and are therefore effective ways of displaying emphathy.
o Contrast: The patient's condition has improved. However, a follow up visit is required.

Sentence Structure
Adverbial Phrase Subject Verb Object/Compliment
blank I suspect the patient has
 developed ectopic
pregnancy.
Comma preferred Unfortunately, I suspect the patient has
developed ectopic
pregnancy.
blank Abdominal revealed slight right iliac fossa
examination tenderness.
Comma preferred On examination, slight right iliac fossa was revealed. blank
tenderness
blank Clinical examination of revealed a large mesioincisal
hard tissues fracture.
Comma preferred On examination, a large mesioincisal was revealed. blank
fracture
Comma preferred Regarding her medical she has been suffering asthma for which she
history, from uses a ventolin inhaler.
Comma preferred On review today, there was no improvement in her
condition.
Comma preferred In terms of his medical he is a heavy smoker and a
history, heavy to moderate
drinker.
Comma preferred Please note, the patient has an appointment with
his physiotherapist at
10 o'clock on Monday.
Comma preferred In addition, there are composite and
 amalgam restorations
on several teeth.
Handy Hint: Do not put a comma between a subject and a verb or a verb and an object.

2. Appositives: This is a noun or a noun phrase that is placed after another noun to explain or identify it. It has a very
important use in the introductory sentence of referral letters as follows.

o Mr Smith, an 80 year old widow, was admitted to hospital with complaints of heart palpitations.
o Thank you for seeing Jordan, a 10 year old boy who presented at my clinic today with a main concern
of pain in tooth 54.
o I am writing to refer Mrs. Bradley, a 42 year old married woman who is suffering from cancer.

3. Conditional Sentences: These sentences are frequently used in the conclusion of a referral letter and the rules
are as follows:

o Use a comma if the if clause is at the beginning of the sentence.

 If you could take over her antenatal care,it would be much appreciated.
 If you have any further questions regarding this patient, please don’t hesitate to call me.
o Don’t use a comma if the if clause is at the end of the sentence.
 It would be greatly appreciated if you could take over her antenatal care.
 Please don’t hesitate to call me if you have any further questions regarding this patient.

4. Complex sentences:

o Use a comma if the dependent clause is at the beginning of the sentence.

 In case of irritation, redness or swelling, please consult your doctor.
  When the results become available, I will forward them to you.
 Because of her deteriorating condition, the patient was admitted to hospital.
o Don’t use a comma if the dependent clause is at the end of the sentence.
 Please consult your doctor in case of irritation, redness or swelling.
 I will forward the results to you when they become available.
 The patient was admitted to hospital because of her deteriorating condition.

5. Comma Splices: A comma splice is two sentences joined together with a comma, but no conjunction. This is an
error as the information must be either joined with a coordinating conjunction such as and/but/or or a new sentence
must be started.

o He does not have any dental experience, he is worried about the pain.(incorrect)
o He does not have any dental experience and he is worried about the pain.(correct)
o He does not have any dental experience. Therefore, he is worried about the pain.(correct)

6. Noun Clauses beginning with that should not be separated by a comma.

o It is also important to know, that a re-check is organised for the 31.5.2009 at 10:30 in order to remove
the suture. (incorrect)
o It is also important to know that a re-check is organised for the 31.5.2009 at 10:30 in order to remove
the suture.(correct)

7. Use commas to separate three or more words, phrases, or clauses written in a series.The final word does
not require a comma and it should be separated by a conjunction such as and or or

o Mrs. Olsen has a history of hypertension, hypothyroidism, glaucoma for which she is on regular
medication. (incorrect)
 o Mrs. Olsen has a history of hypertension, hypothyroidism and glaucoma which is on regular medication.
(correct)

Common Errors
Incorrect Correct
1. On review today Mr Walker has reduced smoking 1. On review today, Mr Walker has reduced smoking
from 20 to 10 cigarettes per day. from 20 to 10 cigarettes per day.
2. On examination today there was a soft fluctuant 2. On examination today, there was a soft fluctuant
swelling palpable on the left cheek swelling palpable on the left cheek
3. Regrettably she has problems with breast feeding 3. Regrettably, she has problems with breast feeding
and caring for the baby. and caring for the baby.
4. Please note he has a prosthetic heart valve. 4. Please note, he has a prosthetic heart valve.

Comma preferred for adverbial phrases. Refer to rule 1

above.
1. I am writing to refer Mr. Jones a 57 year old man 1. I am writing to refer Mr. Jones, a 57 year old man
who was admitted to hospital on the 18th of July, who was admitted to hospital on the 18th of July,
diagnosed with myasthenia gravis. diagnosed with myasthenia gravis.
2. Mr Jones, a 57 year old man was admitted to 2. Mr Jones, a 57 year old man, was admitted to
hospital on the 18th of July, diagnosed with hospital on the 18th of July, diagnosed with
myasthenia gravis. myasthenia gravis.

Comma required for appositives. Refer to rule 2 above.

Apply the comma rule for conditional sentences. Refer to

rule 3 above.
Apply the comma rule for complex sentences. Refer to rule
4 above.
 He has an allergy to nuts, once he was hospitalised  He has an allergy to nuts and was once hospitalised
for severe anaphylactic reaction. for severe anaphylactic reaction.

Refer to rule 6 above.

 Please note that, Daniel has an allergy to peanuts.  Please note that Daniel has an allergy to peanuts.

Apply the comma rule for comma splices. Refer to rule 5

above.
 Mr.Farrah, presented at my surgery today  Mr.Farrah presented at my surgery today
complaining of pain radiating from his left ear to his complaining of pain radiating from his left ear to his
front teeth. front teeth.

Do place a comma between the subject and verb of a

sentence.
 Initial examination revealed, complete edentulous  Initial examination revealed complete edentulous
upper and lower jaws with healthy soft tissue. upper and lower jaws with healthy soft tissue.
 I am writing to request, visits for this family.  I am writing to request visits for this family.

Do place a comma between the verb and object of a

sentence.
Quick Guide to Commas

1. Use commas to separate independent clauses when they are joined by any of these seven coordinating conjunctions: and, but, for, or, nor, so, yet.

2. Use commas after introductory a) clauses, b) phrases, or c) words that come before the main clause.

3. Use a pair of commas in the middle of a sentence to set off clauses, phrases, and words that are not essential to the meaning of the sentence. Use one
comma before to indicate the beginning of the pause and one at the end to indicate the end of the pause.

4. Do not use commas to set off essential elements of the sentence, such as clauses beginning with that (relative clauses). That clauses after nouns are
always essential. Thatclauses following a verb expressing mental action are always essential.

5. Use commas to separate three or more words, phrases, or clauses written in a series.

6. Use commas to separate two or more coordinate adjectives that describe the same noun. Be sure never to add an extra comma between the final adjective
and the noun itself or to use commas with non-coordinate adjectives.

7. Use a comma near the end of a sentence to separate contrasted coordinate elements or to indicate a distinct pause or shift.

8. Use commas to set off phrases at the end of the sentence that refer back to the beginning or middle of the sentence. Such phrases are free modifiers that
can be placed anywhere in the sentence without causing confusion.

9. Use commas to set off all geographical names, items in dates (except the month and day), addresses (except the street number and name), and titles in
names.

10. Use a comma to shift between the main discourse and a quotation.
11. Use commas wherever necessary to prevent possible confusion or misreading.

Capitalisation

Correct use of capitals is an important area to master when writing referral letters. Study the rules of usage below to
ensure you meet the standard conventions.

Rules of Usage

1. Medications and Diseases

o Capitals are required for proper nouns. Proper nouns include the brand name of a drug or registered
trademark of the manufacturer.
 Ritalin
 Voltaren
 Zocor
o The chemical constituent should be written in lower case.
 penicillin
 amoxicillin
o Names of diseases should always be lower case.
 bowel cancer
 high blood pressure
 diabetes
 epilepsy
o Eponyms: Some medical conditions are named after the person who discovered it. In this case the first
word should be capitalised.
  Parkinson’s disease
 Bell’s palsy
o Names of medical procedures do not require capitals.
 orthopantomogram
 x-ray
 caesarian section
o Body parts should always be lower case
 heart
 adrenal gland
 knee

2. Proper Nouns: Proper nouns name something specific as in the examples below. These words must
always be capitalised.

o Job titles
 The Lactation Consultant, Mater Hospital
 The Veterinary Eye Specialist, University of Queensland
o Institutions
 Mary Jones was admitted to Spirit Hospital.
 Dr. Bloomfield works at Weller Point Medical Centre.
o Places including addresses
 168 Wickham Terrace, Spring Hill
 12 Logan Road, Mt Gravatt
 36 Barmore Street, Holland Park
o Titles when they precede the name of a person
 The patient was seen by Doctor Smith.
  Nurse Jones is in charge of the patient's care.

3. Common Nouns: Common nouns do not name any specific institution, place, person or profession.
These words do not need to be capitalised.

o The patient was admitted to hospital.

o The patient does not have a family doctor.
o Steve is a teacher.
o Yoshiro is a doctor.
o Reza is a dentist.

4. Holidays, months, days of the week all need to be capitalised. However seasons do not.

o The baby was born on Christmas Day.

o The patient was admitted to hospital on January 12.
o Please come and see me on Wednesday.
o The vaccination will be available in spring.

5. The pronoun "I" must always be capitalised.

o It was I who treated the patient.

6. Capitalise the first word of a salutation and the first word of a complimentary close.

o Dear Dr. Jameson:

o Yours sincerely,
 Common Errors
Incorrect Correct
 His medical history shows that he is Epileptic.  His medical history shows that he is epileptic.
 Also, I have given Dycal base on 1.1 and dressed it  Also, I have given dycal base on 1.1 and dressed it
with Glass Ionomer Cement. with glass ionomer cement.
 The patient was diagnosed with Type 2 Diabetes.  The patient was diagnosed with type 2 diabetes.
 Mrs. Marsh has a history of Hyperthyroidism,  Mrs. Marsh has a history of hyperthyroidism,
Hypertension and Glaucoma. hypertension and glaucoma.
 The patient is allergic to Penicillin.  The patient is allergic to penicillin.
 The patient suffered from severe Abdominal pain.  The patient suffered from severe abdominal pain.

Refer to rule 1 above.

 Mr. duane thomson presented at my clinic today  Mr. Duane Thomson presented at my clinic today
with the complaint of a broken posterior tooth. with the complaint of a broken posterior tooth.
 The director of nursing  The Director of Nursing
 emergency department  Emergency Department
 Mater hospital  Mater Hospital
 84 Monash road  84 Monash Road
 The patient was seen by doctor Jones.  The patient was seen by Doctor Jones.

The above words are all proper nouns. Refer to rule 2

above.
 As per the General Practitioner’s order, we are doing  As per the general practitioner’s order, we are doing
daily home visits and wound dressing and also daily home visits and wound dressing and also
 assisting him with his showers. assisting him with his showers.
 Please see your Pharmacist for advice.  Please see your pharmacist for advice.
 Ms. Gatsby is a University student.  Ms. Gatsby is a university student.

The above words are all common nouns. Refer to rule 3

above.
 The patient first visited my surgery in march, 2008.  The patient first visited my surgery in March, 2008.
 Mrs. Green will be discharged from hospital on  Mrs. Green will be discharged from hospital on
wednesday. Wednesday.
 Symptoms of hay fever are worse in Spring.  Symptoms of hay fever are worse in spring.

Refer to rule 4 above.

 The patient requested that i prescribe antibiotics for  The patient requested that I prescribe antibiotics for
the virus. the virus.

Refer to rule 5 above.

 dear Dr. Roberts:  Dear Dr. Roberts:
 yours sincerely,  Yours sincerely,

Refer to rule 6 above.

Common Errors
 Common Mistakes Regarding Physical Description
Incorrect Correct
Advice was given to reduce her weight. 1. Advice was given to reduce weight.
After the verb reduce it is not necessary to follow with a 2. The patient was advised to reduce weight.
pronoun. So you is not required. Simply say: 3. A reduction of weight was advised.
I advised him to reduce weight, or, you need to reduce weight.
In addition, she had lost her weight. 1. In addition, she had lost weight.
After the verb lose it is not correct to follow with a pronoun. 2. In addition, she has lost a further 11 kg of weight over the
past 2 months.
3. In addition, the patient’s weight has significantly
reduced from 61 kg to 50 kg over the past 2 months.
He is now obese with a 99kilos weight and a 170cm height. 1. He is now obese with a weight of 99 kg and a height of
The use of the correct verb & noun form and associated 170cm. (noun form)
grammar is difficult. Refer opposite for correct usage. 2. He weighs 99 kg and is 170cm tall. (verb form)
3. He weighs 99kg and is 170cm in height. (verb form)

1. Today’s examination revealed multiple missing teeth, 1. Today’s examination revealed multiple missing teeth,
various carious lesions and a periodontal pocket of depth various carious lesions and a periodontal pocket depth of
4-9mm. 4-9mm.
2. There are several periodental pockets with about 4-9 2. There are several periodontal pockets which are about
mm in depth. 4’9 mm in depth or
Correct word order is: 3. There are several periodontal pockets with a depth of
Depth of 4-9mm about 4-9 mm.
Height of 173cm 4. His height is 173cm.
Length of 20 m
Weight of 78kg
3. His height was 173cm. Weight can change but height
can not so don’t use past tense.

1. He was overweight 85 Kg with respect to his height 1. He was overweight at 85 kg with respect to his height
173 cm. of 173 cm.
This sentence is a shortened version similar to the case
notes. It is important to write in full sentences.

Difficult Words

The English language is governed by rules. However, there are also many exceptions to these rules and words which
do not follow the normal or expected pattern are those which often cause problems. Study this list carefully so that
you can improve your grammatical accuracy and knowledge.

Complain Vs Complaint
Complain is a verb

 The patient complained of severe abdominal pain.

Complaint is a noun
  The patient presented with a complaint of severe abdominal pain.

Note 1: Complaint is a countable noun. so it can be used in the plural form or singular with an article.
Note 2: The two main prepositions used with complain are: complain of & complain about.

 Mr. Cochrane presented with complaints of nausea, headache and fever. (plural)
 Mr. Cochrane presented with a complaint of nausea. (singular with article)

Incorrect Correct
 The patient complaints of chest pain and her blood  The patient complains of chest pain and her blood
pressure is high. pressure is high.(verb)
 The patient presented with a complain of chest pain.  The patient presented with a complaint of chest
 The patient presented with complaint of chest pain. pain.(noun)
 He presented to my office on 23/03/2008  The patient presented with a complaint of chest
complaining on severe pain associated with the pain. (article required)
lower left first molar.  He presented to my office on 23/03/2008
complaining of severe pain associated with the lower
left first molar.

Suggest & Recommend Vs Advise

Suggest, recommend and advise are all words commonly used in referral letters to report information were given to
the patient. However their rules of use differ and result in errors. Here are some examples of their correct and
incorrect usage.
Incorrect Correct
 I have suggested him to see you next week.  I suggested (that) he see you next week.
  I suggested her to return in morning as she required  I advised him to see you next week
further blood test and assessment.  I suggested (that) she return in morning as she
 I recommended him to rest for 3 days. required further blood test and assessment.
 I advised her to return in morning as she required
Explanation:The words suggest & recommend cannot be further blood test and assessment.
followed by an object pronoun such as him/her whereas  I recommended (that) he rest for 3 days.
advise can.

Explain Vs Tell
Explain and tell also have different rules which cause confusion
Incorrect Correct
 I explained them that unsuccessful conception was  I explained to them that unsuccessful conception
not unusual in their case. was not unusual in their case.
 I have already explained the couple the basic advice  I told them that unsuccessful conception was not
regarding conception. unusual in their case.
 I have already explained to the couple basic advice
Explanation: The word explain cannot be followed by a regarding conception.
pronoun or noun without the preposition to whereas tell  I have already told the couple basic advice regarding
can. conception.

Advise Vs Advice
Advise is a verb

 We advise patients on how to take their medication.

Advice is a noun

 We give advice or provide advice to patients on how to take their medication.

Note 1: The noun advice is uncountable so it can not be used in plural form. i.e. advices is incorrect as is an advice.

 I gave some advice to the patient regarding her medication.

Note 2: The pronunciation is different: advise advice

Incorrect Correct
 It would be greatly appreciated if you could make a  It would be greatly appreciated if you could make a visit
visit to this family and advice his parents regarding the to this family and advise his parents regarding the
recommended vaccines for both children. recommended vaccines for both children. (verb)
 I am writing to refer this patient to you for an advice  I am writing to refer this patient to you for advice
regarding the management of his bilateral inguinal hernia. regarding the management of his bilateral inguinal
 I gave an advice to the patient regarding her hernia(noun)
medication.  I gave some advice to the patient regarding her
 I gave advices to the patient regarding her medication.(noun)
medication.  I gave advice to the patient regarding her
 Please advice the patient on how and when to take medication.(noun)
their medication.  Please advise the patient on how and when to take
their medication. (verb)

Request
Request can be both a verb and noun.
Request as a verb
  The patient requested painkillers. (verb form)

Request as a noun

 The patient made a request for painkillers. (noun form: request+for)

Incorrect Correct
 The patient requested for new dentures.  The patient requested new dentures. (verb)
 Ms. Green requested about IVF treatment.  The patient made a request for new dentures.
(noun)
Explanation: The common mistake is to use the verb form  Ms. Green requested IVF treatment.(verb)
plus preposition which incorrect.  Ms.Green made a request for IVF treatment. (noun)

Affect Vs Effect
Affect is a verb

 The patient has not been affected by the treatment.

Effect is a noun

 The treatment has had no effect.

Note: The pronunciation is the same.

Incorrect Correct
 She has also been effected by glaucoma for the past  She has also been affected by glaucoma for the past
4 years. 4 years. (verb)
 The side affects of this medication are unknown.  The side effects of this medication are unknown.
(noun)

Widow or Widower

 Widow (noun) refers to a woman whose husband has died and who has not remarried.
 Widower (noun) refers to a man whose wife has died and who has not remarried.
 Widowed (adjective) refers either a man or woman whose spouse has died and has not remarried.

Incorrect Correct
 I am writing to refer Mrs. Saunders, a 58-year-old  I am writing to refer Mrs. Saunders, a 58-year-old
widowed who admitted with pain, dehydration and widow who admitted with pain, dehydration and
nausea. nausea.(noun)
 I am writing to refer Mr. Saunders, a 60-year-old  I am writing to refer this patient, a 58-year-old
widow who complained of pain in his upper right widowed woman who admitted with pain,
second molar. dehydration and nausea.(adjective)
 I am writing to refer Mr. Saunders, a 60-year-old
widower who complained of pain in his upper right
second molar.(noun)

History
History is always present, never past because you can’t erase it! Therefore you need to use simple present tense not
past tense when using this expression.
Incorrect Correct
 Mrs. McGowan had a history of heart palpitation of 3  Mrs. McGowan has a history of heart palpitation of 3
day duration. day duration.

Allergy Vs Allergic
Allergy is a countable noun

 Michael has no known allergies.(plural)

 Michael has a peanut allergy. (singular)

Allergic is an adjective

 Michael is allergic to peanuts.

Incorrect Correct
 In addition, he is known allergic to nuts for which he  In addition, he has a known allergy to nuts for which
was admitted to hospital with anaphylaxis 2 years he was admitted to hospital with anaphylaxis 2 years
ago. ago.(noun)
 Regarding his medical history he is allergy to sulphur  In addition, he is known to be allergic to nuts for
containing drugs. which he had been admitted in the hospital with
anaphylaxis 2 years ago.(adjective)
 Regarding his medical history he has an allergy to
sulphur containing drugs.(noun)
  Regarding his medical history he is allergic to
sulphur containing drugs.(adjective)

Confident Vs Confidence
Confident is an adjective

 The patient is not confident in her ability as a mother.

Confidence is a noun

 The patient lacks confidence in her ability as a mother.

Incorrect Correct
 The patient has not confident social situations.  The patient has no confidence in social situations.
 The patient is not confidence in social situations. (noun form)
 The patient is not confident in social situations.
(adjective form)

a few/few & a little/little

Few and a few is used with plural nouns, and little and a little is used with uncountable nouns. Little and few have
negative connotations and are similar in many to not much/ not many. A little and a few have positive
connotations and are similar in meaning to some. Mixing up these words therefore will completely change the
meaning of the sentence.
 Incorrect Correct
 The patient has reduced speech output and a little  The patient has reduced speech output and little eye
eye contact. contact.(negative connotation required here)
 There are few ways to help identify the possibility of  There are a few ways to help identify the possibility
threadworms such as checking the anus of your of threadworms such as checking the anus of your
children at night and frequent scratching. children at night and frequent scratching.(positive
connotation required)

during/while
During is followed by a noun

 During hospitalisation the patient made a full recovery.

 The patient had many visitors during his stay in hospital.

While is followed by a phrase or gerund: ____ing

 While in hospital, the patient made a full recovery.

 The patient had many visitors while recovering in hospital.

Incorrect Correct
 He twisted his ankle during playing squash 3 months  He twisted his ankle during a game of squash 3
ago. months ago.
 He twisted his ankle while playing squash 3 months
ago.
 following/followed by

Incorrect Correct
 She was admitted to our hospital followed by a  She was admitted to our hospital following a collapse
collapse at home with dehydration,nausea and at home with dehydration,nausea and severe pain.
severe pain.
Correct as it means the collapse occurred before being
Incorrect as it means the patient was admitted to hospital admitted to hospital.
first, then collapsed.

Years Vs Year

Incorrect Correct
I am writing to refer this patient,63 years old man who lives 1. I am writing to refer this patient, a 63- year- old man,
alone. who lives alone.
In this sentence there are two mistakes: 2. There are two 63-year-old men in the waiting room.
1. the expression is a phrase and therefore requires an
article “a “ to precede the phrase a 63-year-old man. An
article is required because the noun man is singular.
Compare with: There are two 63-year-old men in the
 waiting room.
2. Years is an adjective in this sentence (it describes the
age of the man) and adjectives are uncountable.
This patient is 63 year old. This patient is 63 years old.
In this sentence the word years is a noun preceding an adjective
old. Nouns can be countable so in this case you must make it
plural.
Her father died at 50 year old of bowel cancer 1. Her father died at 50 years of age of bowel cancer
In this case at is a preposition and needs to be followed by a 2. Her father died at the age of 50 of bowel cancer
noun or noun phrase, rather than the adjective” old”. See 3. Her father died when he was 50 years old of bowel
column on the right for possible correct choices. Year is a noun cancer.
in this case so it should be written in plural form.
Other examples
1. In addition, he had a habit of thumb sucking until age of 1. In addition, he had a habit of thumb sucking until the age
five years. of five.
2. In addition he had a habit of thumb sucking until he was 2. In addition, he had a habit of thumb sucking until he was
five years age. five years of age.
3. Regarding the medical history, Alfie has a history of 3. In addition, he had a habit of thumb sucking until he was
thumb sucking until the age of 5 years, five years old.
1. In addition she has fillings, crowns, good dental hygiene 1. In addition she has fillings, crowns, good dental hygiene
and a 13 years old chrome /cobalt removable partial and a 13 year old chrome /cobalt removable partial
denture. denture.
Years is an adjective in this sentence (it describes the age of
the denture) and adjectives are uncountable.
 Phrasal Verbs and Prepositions

A to Z of Phrasal Verbs and Useful Vocabulary

Letter Expression Example sentence
a.  admitted to  The patient was admitted to our hospital in March 2008 for the first time.
 associated with
 advised to  Mr. Booth first came to see me on 12/08/08 complaining of shortness of breath
 advice on which was worse when he was lying down. It was associated with a tightness in the
 allergies chest and coughing.
 allergic to  She was advised to return the next day for a blood test and follow up consultation.
 arrived at (verb)
 arrived in
 For both children advice on recommended vaccines will be necessary.
(noun)

 She is not on any medication and has no known allergies.

 Please note, the patient is allergic to penicillin.

 The patient arrived at my surgery in a depressed state.

 The family arrived in Australia in 2007

b.  believe  I believe the patient needs urgent assessment and hospital admission
 borderline  She was noted to be overweight and has borderline hypertension.
c.  consistent with  I am writing to refer Mr. Walker a 40 year old married patient, presenting with signs
 commence and symptoms consistent with prostatic enlargement.
 commence on  IV fluids were commenced in order to improve hydration.
 Therefore I commenced him on omeprazol 20 mg daily and strongly advised him to
stop smoking cigarettes and stop drinking alcohol. (active)
 She was commenced on 15gram alepam 1 tablet nightly for her current anxiety and
sleeplessness. (passive)

 confidence in
 She lacks confidence in caring her baby in terms of breast feeding and
bathing.

d.  discharge on  He will be discharged on the 12th of August.

 deteriorate  Since 28th of July her condition has deteriorated with occasional disorientation.
 deny  She denied vomiting and she was vague reporting about laxatives.
 difficulty in  Mr. MacIntosh presented to me with the complaint of difficulty in passing urine.
 diagnosed with  I am writing to refer my patient, Fletcher, a nine year old Labrador cross dog who is
 diagnosis of diagnosed with high grade lymhoma. (verb)
 Histological results confirmed the diagnosis of high grade lymphoma.(noun)
e.  evidence of  Examination findings revealed evidence of an enlarged prostate.
 enclosed  I have enclosed the radiograph for your convenience.
f.  to follow  The patient was advised to follow a low fat diet.

h.  history  The patient first attended me yesterday evening with a one day history of lower
 abdominal pain
 Mr. Abrahim has a positive family history of prostate cancer
i.  indicate  The family has indicated that they need an interpreter who speaks Farsi or Arabic
 indicative of during follow-up visits with this family.

 However, there was slight swelling in the right groin indicative of inguinal
 inconspicuous hernia

 His family and social history is inconspicious.

k.  known  She is a known asthmatic since childhood and is on Budesonide inhaler for the same.

m.  to make an  I have made an appointment for her through your receptionist.

appointment
n.  on examination  On examination, her blood pressure was 180/90 mm Hg with a regular pulse of
70 beats per minute.
o.  occasions  Today she presented very anxious and depressed as she had noted some blood in her
motions on two separate occasions.
p.  provisional  Provisional diagnosis suggests prostate cancer.
 present at  Mr Gates presented at my clinic yesterday at 7pm with a complaint of lower back
 present to pain.
 Today, he presented to me complaining of a regular dull ache in the groin.
q.  queries  If you have any further queries, please do not hesitate to contact me.

r.  reveal  Examination today revealed a significantly increased right groin swelling.

 risk factors  His risk factors include: smoking 20 cigarettes per day, lack of exercise and a strong
  a routine recovery family history of hypertension.
 reluctant to  He has made a routine recovery and his wounds appear to be healing well.
 rule out  He is reluctant to seek treatment.
 remarkable  I believe she needs an urgent assessment to rule out bipolar disorder
findings  There were no other remarkable findings.

s.  suggestive of  Miss Jones is suffering from the signs and symptoms suggestive of ectopic
pregnancy.
 suspicious of  I am writing to refer this patient, a 60-year-old women,with symptoms suspicious of
bowel malignancy
 suffering from  Ms.Tylor has been suffering from diabetes and she is administering insulin injection
 signs and by herself.
symptoms  He is a 40-year-old man who is suffering from signs and symptoms suggestive of
peritonitis with perforated gastric ulcer.
t.  treated with  He also has been suffering from hypertension which has been treated with Atenolol
50 mg daily.
u.  underlying  I would appreciate your assessment of this girl to find out whether he has any
 under control underlying psychological problems.
 uneventful  Currently, her pain is under control with medication and she is tolerating fluids.
 urgent  Her second pregnancy and delivery were uneventful.
 unremarkable  I would appreciate if you could give urgent attention to Mrs. Woods' problem.
 to undergo  Cardiovascular examination was unremarkable and her electrocardiogram was
treatment/surgery normal.
/an operation  She underwent colonoscopy three years ago which was normal. (simple past)
 During hospitalization, the patient has undergone an electromyogram and X-ray.
(present perfect)
 v.  vital signs  Her vital signs were normal, but she was overweight (85 kg). Therefore she was
advised to reduce weight and do exercise.
w.  with a complaint  Mr Gates presented at my clinic yesterday at 7pm with a complaint of lower back
of pain.

Prepositions
Prepositions are a difficult area of language to fully master as their usage is not governed by strict rules. The best way
to learn prepositions is by regular reading so that you can slowly absorb and become comfortable with their correct
use. However, it is possible to memorise the correct use of a selection of prepositions in order to use them accurately
in writing the referral letter.

Prepositions of Time
In: In is used for longer On: On is used for days At: At is used for the time Some words require no
periods of time and dates and some time of day and for some preposition
expressions expressions
 In November  On Monday  At 6 o'clock  Yesterday
 In Spring  On 20 November  At night  Today
 In 2006  On Christmas day  At lunchtime  Tomorrow
 In the past  On his birthday  At that time  Last week
 In the future  On review  At the moment  This week
 In the morning  On examination  At the age of 45  Next week
 In the afternoon  On investigation  At birth
 In her childhood  On presentation
 In his twenties  On two occasions
Prepositions of Place
In: In is used for inside of On: is used for the surface area of At: At is used for a place of activity
something something
 In Australia  On the skin  At home
 In hospital  On the ground floor  At work
 In surgery  At the wound site
 In the stomach  At the clinic

Common Errors
Incorrect Correct
 His father died of cancer during the age of 50.  His father died of cancer at the age of 50.

 In examination today, the patient was anxious and  On examination today, the patient was anxious and
distressed. distressed.

 Initial examination on today revealed inflammed  Initial examination today revealed inflammed gums.
gums.

 On December 2006, the patient had his wisdom  In December 2006, the patient had his wisdom teeth
teeth removed. removed.
 The patient's family arrived at Australia in last year.  The patient's family arrived in Australia last year.

Cohesion

Useful signal markers

Letter Signal Marker Example Sentence
a.  ______as well  She suffers from oedema as well as bladder incontinence and only tolerates
as______ fluids.
 as a result of  This child was admitted with Acute Meningoencephalitis as a result of a
complication following Mumps.
 as a result  Let me inform you that that the patient has proven to be uncooperative during
his dental treatments. As a result, I would recommend the treatments be
carried out with a general anaesthetic.
 On vaginal examination cervical excitation was noted along with tenderness in
the right fornix.
 along with
 She looked very anxious and was having trouble sleeping. Apart from this, no
abnormalities were found on rectal, cardiovascular and respiratory
 apart from this
examinations.
 at that time
 Initially, I saw the patient six months ago when she complained of
constipation. At that time, her physical examination was normal.

b.  besides that  The patient has smoked 40 cigarettes a day for 25-30 years. Besides that he
  because of this has type 2 diabetes.
 based on  He smokes 20 cigarettes and drinks 2 beers every day. Because of this, he has
been told to cease smoking and to reduce alcohol.
 Furthermore, a fine needle aspiration was taken and was investigated. Based
on that, I suggest the dog has developed lymphoma.
c.  consequently  The depth of periodontal pocket was 3.4mm.Consequently, he has undergone
extensive treatment for carious lesions and oral hygiene maintenance.

d.  during_________  During hospitalization, his vital signs have been monitored and he has been
 duration assisted with his showers.
 On 15/2/08, she presented complaining of lower abdominal pain of 1 day
 despite duration.

 Despite various dental treatments and regular dental cleaning, his general
gum condition is only fair.

f.  for this reason  Mr. Fox's blood pressure was elevated and he was overweight. For this reason
the patient was advised to do exercise and follow a healthy diet.
h.  hence  The carious lesions on 65 are reasonably deep and hence the tooth has to be
extracted.
 however
 The patient regularly visits the dentist and her oral hygiene status is good.
However, her gums are inflamed.

i.  in terms of ___  In terms of her medical history, she has mild hypertension and a 12 year
history of diverticulitis.
 in order to
  in addition  I have prescribed agleam in order to reduced anxiety.
 Regarding the medical history, Alfie had a history of thumb sucking until the
 in the meantime age of 5. In addition, he is epileptic and uses dylantin to control the attacks.
 I have planned to review him in two months to monitor his blood pressure and
smoking reduction. In the meantime, I believe he needs urological assessment.
 in case of
 In case of any irritation, redness or swelling of the skin, discontinue the
treatment and consult your doctor immediately

m.  may I remind you  May I remind you that both the teeth will require root canal treatment and
that…. crown.
 my main concern is  My main concern is that the patient is reluctant to breastfeed and confident in
that……. caring for her baby.

n.  It should be noted  It should be noted that they may have a problem with communicating in
English as they understand limited English.
o.  over……  Over the past week, she has remained free from severe pain and has been
tolerating a fluid diet.
 She first presented to me on 3.7.06 with several episodes of heart flutter over
the previous few weeks.
 on review today,  On review today, the patient has reduced smoking to 10 cigarettes a day,
attended gym twice a week and lost 7kg so far.
p.  please note  Please note, he has an allergic reaction to nuts.
 r.  regarding  Regarding his medical history, Jordan suffers from eczema and asthma for
which he receives treatment twice a year.
 regrettably  Regrettably, she complains of mild constipation and weakness.
 recently  Recently, she has been prescribed Karvea 150mg and Oroxine 0.1mg per day,
Timoptol Eye Drops 0.5% twice a day and Normison 10mg as required.
s.  since then  His urinalysis and examination were normal except obesity and borderline
hypertension. Since then, he has been doing regular exercise and has managed
to lose 8kg of weight
t.  therefore  Her vital signs were normal, but she was overweight (85 kg). Therefore she
 the reason for was advised to reduce weight and do exercise.
 The reason for the referral is to consider a possible prostate biopsy regarding
the patient’s condition.
u.  up until now,  Up until now, Mr. Hutton has lead a very unhealthy life.
 unfortunately  Unfortunately, she is not expected to survive more than 3 months.
w.  with regard to  I am writing with regard to this patient, a 57 year-old married man who is
under our care with the diagnosis of myasthenia gravis.
Example Cohesive Paragraphs
Doctors
Initially, I saw Mr. Jones last month when he came for check-up. At this time his blood pressure showed a mild elevation
(165/90).Also his weight was above the normal limit (85 kg while his height is 173 cm). However, the cardiovascular
examination and the urinalysis were normal. Therefore I advised him to lose weight, to stop smoking cigarettes and to
come for a review visit within one month. A prostate specific antigen test was requested to be done before the next visit.
Dentists
Initial examination on 20/ 02/ 2008 revealed that 54 has a temporary filling with a cavity extending through the furcation.
Based on the bitewing radiological findings, I advised both 54 and 65 be extracted along with the construction of a space
maintainer. Moreover I advised the filling of carious 55 and fissure sealant for all 6’s. In my view, general anaesthesia
is the proper sedation as the patient is known to be uncooperative in a dentist chair.
Nurses
When admitted to this hospital, Mr. Jagger complained of haemetemesis, anorexia, dizziness associated with weight loss
and anaemia. He also was suffering from severe epigastric pain after meals. Therefore, his stool was examined and an
endoscopy has been performed.

Complex Sentences

Relative Clauses

In the introduction of a referral letter it is common practice to introduce the patient and provide some relevant details
relating to their situation or condition. The relative clause allows writers to do this in a clear and concise manner.

Definition: A relative clause is the part of the sentence which provides information about the patient. They can be
divided into two types, defining and non-defining. Defining clauses provide details about the noun being referred to.
Commas are not required.
Non-defining clauses provide extra information about the noun being referred to but do not define it. Commas are
required.
Defining Non-defining
 I am writing to refer this patient who is due to be  I am writing to refer this patient, who is due to be
discharged today. discharged today, for ongoing physiotherapy
 treatment.
Explanation: The relative clause defines the object of the
main clause i.e Which patient? The patient who is being
discharged. Explanation: The relative clause provides extra
information (patient is due to be discharged) about the
object of the main clause but does not define it. It could be
removed from the sentence and the meaning would still be
clear: I am writing to refer this patient for ongoing
physiotherapy treatment.
 I am writing to refer Mrs. Patterson, a 36-year-old  Mrs. Patterson, who is a 36-year-old married
married woman who is suffering from mild woman, is suffering from mild depression.
depression.

Explanation: The relative clause provides extra

Explanation: The relative clause defines the object of the information (Mrs. Patterson is a 36 year old woman) about
main clause i.e Who? Mrs. Patterson, a 36-year-old the subject of the main clause but does not define it. It
woman. could be removed from the sentence and the meaning
n.b. In this sentence, the first comma allows extra would still be clear: Mrs Patterson is suffering from mild
information to be added about Mrs. Patterson. depression.

Handy Tip
No name=no comma
In example 1 below, no comma is required as the relative clause is defining the person being referred to. In example
2, the relative clause does not define the person being referred to because it is already known. Therefore, If you
include the patient's name, commas are required.
 1. The doctor who performed the operation is from Iraq.
2. Doctor Yousif, who is from Iraq, performed the operation.

Incorrect Correct
 Mr. Holmes who lives with his wife in a government  Mr. Holmes, who lives with his wife in a government
flat, is an aged care pensioner. flat, is an aged care pensioner.
 Mr. Holmes lives with his wife in a government flat
Explanation: Commas required as it is a non-defining and is an aged care pensioner.
relative clause. You can also express this information in a
compound sentence.
 Mr. O'Riley, who lives alone in his own home, and  Mr. O'Riley, who lives alone in his own home, works
works as a fencing contractor and has only one as a fencing contractor and has only one brother.
brother.

Explanation: After the second comma a verb is required.

i.e Mr O'Riley works..
 Mrs. Peterson who recently moved to our retirement  Mrs. Peterson recently moved to our retirement
village following her husband's death. village following her husband's death.
 Mrs. Peterson, who recently moved to our
Explanation: No relative pronoun needed here as it is a retirement village following her husband's death,
simple sentence. has a history of hypertension.

 Mr. Brown presented at my clinic today with a  Mr. Brown presented at my clinic today with a
complaint of fractured front teeth in a traumatic car complaint of fractured front teeth which occurred in
accident. a traumatic car accident.
 Mr. Brown presented at my clinic today with a
Explanation: A relative clause is required to define how the complaint of fractured front teeth. This occurred in a
teeth were fractured. Alternatively it can be written as two traumatic car accident.
separate sentences.
 I am writing regarding Mr. Jones, a 35  I am writing regarding Mr. Jones, a 35 year-old-male
year-old-male, who was recently diagnosed with who was recently diagnosed with with tuberculosis.
with tuberculosis.

Explanation: Second comma not required as it is a defining

relative clause, i.e it defines Mr. Jones
 I am writing to refer Mrs. Margaret Green, a 66 year  I am writing to refer Mrs. Margaret Green, a 66 year
old widow with three children, with complaints of old widow with three children who is complaining of
chest pain. chest pain.

Explanation: Relative clause required here as two

prepositional phrases is confusing.
 I am writing to refer, Ms. Abbot, a 58 year old widow  I am writing to refer Ms. Abbot, a 58 year old widow
admitted with pain, dehydration and nausea. who was admitted with pain, dehydration and
nausea.
Explanation: Incorrect comma placement and relative
clause required.
 Mr. Fisher was admitted to hospital with the  Mr. Fisher was admitted to hospital with the
diagnosis of obstructive artery disease and end with diagnosis of obstructive artery disease which
quadruple artery bi-pass grafts. required quadruple artery bi-pass grafts.

Explanation: A relative clause is required to define the

treatment.
  I am writing to refer this 14-year-old boy to you who  I am writing to refer this 14-year-old boy who came
came to me complaining of a sprained ankle. to me complaining of a sprained ankle.

Explanation: The relative pronoun must follow the noun it

is referring to.
 I am writing to refer this patient, a 39 year old  I am writing to refer this patient, a 39 year old
widowed woman, who is under our care after being widowed woman who is under our care after being
injured in a car accident. injured in a car accident.

Explanation: No comma required as it is a defining relative

clause.
 Mr. Roberts who is a 72-year-old retired gentleman  Mr. Roberts, who is a 72-year-old retired gentleman,
was admitted to hospital for acute cerebral infarction was admitted to hospital for acute cerebral infarction
on 08/03/10. on 08/03/10.

Explanation: Commas required as it is a non-defining

relative clause and provides extra information about Mr.
Roberts.
 I am writing to explain Mr. Clarke's current situation,  I am writing to explain Mr. Clarke's current situation.
who has been a patient of mine for a long time. He has been a patient of mine for a long time.
 I am writing to refer Mr. Clarke, who has been a
Explanation: The relative pronoun must be added directly patient of mine for a long time. Currently, he is
after the person you are referring to. suffering from........
 Clauses of Contrast

Contrast can be expressed by joining two clauses with the following linking words: although/but/despite/despite the fact
that/even though/however/in spite of/on the other hand/whereas/while. A comma is used to separate the two clauses as
illustrated below.

<!--[if !supportLists]--><!--[endif]-->Although her condition has improved, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Her condition has improved, but she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Despite an improvement in her condition, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Despite the fact that there has been an improvement in her condition, she
is still very weak.

<!--[if !supportLists]--><!--[endif]-->Even though her condition has improved, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Her condition has improved. However, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Inspite of an improvement in her condition, she is still very weak

<!--[if !supportLists]--><!--[endif]-->While her condition has improved, she is still very weak.

Rules for linking words

<!--[if !supportLists]--><!--[endif]-->Although/Even Though + clause (underlined below)

 e.g. Although + her condition has improved, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Despite/Inspite of + noun or gerund (underlined below)

e.g. Despite an improvement in her condition, she is still very weak.

Despite overcoming her illness, she is still very weak

<!--[if !supportLists]--><!--[endif]-->Despite the fact that/Inspite of the fact that + clause (underlined
below)

<!--[if !supportLists]--><!--[endif]--> e.g. Despite the fact that there has been an improvement in her condition,
she is still very weak.

Despite the fact that her condition has improved, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->However : A comma is required after however

e.g. Her condition has improved. However, she is still very weak

Common Mistakes

Incorrect Correct
<!--[if !supportLists]--><!--[endif]-->Inspite of providing <!--[if !supportLists]--><!--[endif]-->Inspite of our
with exercises and compensatory techniques she was provision of exercises and compensatory techniques,
unable to cope with training due to an increase in pain. she was unable to cope with training due to an increase
 Explanation: providing is incorrect, as it was the patient in pain.
who was provided excercise, in such cases you have 2 choices
<!--[if !supportLists]--><!--[endif]-->Inspite of
<!--[if !supportLists]-->1. <!--[endif]-->Use a noun being provided with exercises and compensatory
phrase In spite of our provision of exercises techniques, she was unable to cope with training due
to an increase in pain.
<!--[if !supportLists]-->2. <!--[endif]-->Use passive
voice In spite of being provided with excercise
<!--[if !supportLists]--><!--[endif]-->Although she has <!--[if !supportLists]--><!--[endif]-->Although she has
improved, but she is still very weak improved, she is still very weak.

<!--[if !supportLists]--><!--[endif]-->She has improved,

Explanation: This sentence has two linking words so one must
be omitted. but she is still very weak.

<!--[if !supportLists]--><!--[endif]-->Despite of regular <!--[if !supportLists]--><!--[endif]-->Despite regular

follow up, plaque and tartar were detected over cervical follow up, plaque and tartar were detected over cervical
and bucal surfaces of the denture teeth. and bucal surfaces of the denture teeth.

<!--[if !supportLists]--><!--[endif]-->Inspite of regular

Explanation: There is no linking expression “despite of”
follow up, plaque and tartar were detected over cervical
and bucal surfaces of the denture teeth.
<!--[if !supportLists]--><!--[endif]-->Despite of this <!--[if !supportLists]--><!--[endif]-->Despite this advice,
advice, he regularly drinks 2~4 glasses of wine every he regularly drinks 2~4 glasses of wine every night as
night as well as 1~2 glasses of scotch at weekends. well as 1~2 glasses of scotch at weekends.

Explanation: As above <!--[if !supportLists]--><!--[endif]-->Inspite of this

advice, he regularly drinks 2~4 glasses of wine every
night as well as 1~2 glasses of scotch at weekends

Clauses of Purpose
Purpose clauses allow the writer to express why a certain action was taken in the past or why a certain action needs to be taken in
the future. It can be expressed by joining two clauses with the following linking words: in order to; so that. A comma is required
when the subordinate clause comes before the independent clause.

 In order to reduce weight, a low fat diet has been recommended.(quite formal and suitable for referral letters)
 A low fat diet has been recommended in order to lose weight.
 A low fat diet has been recommended so that the patient can lose weight. (casual expression and used more in informal
writing or spoken English)

Rules

 in order to + infinitive: Further investigation is required in order to rule out bowel cancer.
 so that + past reference: A general anesthetic was given so that the patient would not feel pain.
 so that+ future reference: A general anaesthetic needs to be given so that the patient will not feel any pain.

Handy Tip: in order to rule out + disease name is a useful phrase for introductions or conclusions.

 In order to rule out ectopic pregnancy, I would appreciate your urgent assessment.
 The patient wants to have a scan for nuchal translucency in order to rule out Down's Syndrome.
 Incorrect Correct
 In order for alleviation of pain, the patient was  In order to alleviate of pain, the patient was
prescribed paracetamol. prescribed paracetamol.

Explanation: In order must be followed by to + infinitive

verb, not for + noun

This page is under construction, more examples coming soon.

Clauses of Reason

In referral letters it is often necessary to state why a certain action was taken and clauses of reason allow the writer
to do this in a clear manner. It can be expressed by joining two clauses with the following linking words: due to/due
to the fact that; for this reason; because/ because of.

Examples

 Due to failure to progress and fetal stress, an emergency caesarean section was performed.
 Due to the fact that there was failure to progress and fetal stress, an emergency caesarean section was
performed. (formal)
 There was evidence of poor progress and fetal stress. For this reason, an emergency caesarean section was
performed.
 Because there was evidence of poor progress and fetal stress, an emergency caesarean section was
performed.
  Because of failure to progress and fetal stress, an emergency caesarean section was performed.

Rules

due to/because of + noun (underlined below)

Example: Due to a low fat diet, the patient's health improved.
The patient's health improved due to a low fat diet.
Because of a low fat diet, the patient's health improved.
The patient's health improved because of a low fat diet.

 due to + gerund (-----ing form)

Example: Due to losing weight, the patient's health improved.

 for this reason+ clause (underlined below)
Example: The patient was placed on a low fat diet. For this reason, her health improved.
 because + clause
Example: Mrs. Healy's health improved because she was on a low fat diet.
Because she was on a low fat diet, Mrs. Healy's health improved.

 due to the fact that + clause

Example: The patient's health improved due to the fact that she was on a low fat diet.
Due to the fact that Mrs Healy was on a low fat diet, her health improved.

Handy Tip: due to + ing form allows the writer to express meaning clearly and concisely so it is useful in referral
letters.
Comma placement
a comma is required when the subordinate clause comes before the independent clause. However, if the
independent clause comes first, no comma is required. Click here for more details.

Incorrect Correct
 The patient is feeling lonely and isolated due to lose  The patient is feeling lonely and isolated due to
her usual social contacts. losing her social contacts. (clear and concise)
 The patient is feeling lonely and isolated due to the
fact that she lost her social contacts. (formal and a
Explanation: Incorrect word form and sentence structure bit wordy)
after due to
 His mother had difficulty in caring for both her son's  His mother had difficulty in caring for both her son's
illness and looking after two other small children due illness and looking after two other small children due
to sick. to her sickness.
 His mother had difficulty in caring for both her son's
Explanation: Incorrect word form and sentence structure illness and looking after two other small children due
after due to to being sick.

 Recently, the Mr Hutton stopped playing sport  Recently, the Mr Hutton stopped playing sport
because muscle soreness. because of muscle soreness.
 Recently, the Mr Hutton stopped playing sport
Explanation: Incorrect word form and sentence structure because he had muscle soreness.
after because of

Clauses of Time
A very important part of referral letters is summarizing the patient history and order of events in the case notes. The
use of time conjunctions help the writer express these relationships clearly. Commonly used conjunctions include:
ago, during, when, while, since, first, on the next visit, at that time, after, later, in .......... time etc. etc.

Example sentences

 The patient first saw me three months ago complaining of painful wisdom teeth.
 During hospitalization, the patient had surgery to remove a suspicious lesion on his lip.
 When Mr. Matthews is discharged, he will need assistance with showering and general household chores.
 While you are on this medication, please do not drive or consume alcohol.
 Since being admitted 3 weeks ago, the patient has steadily improved and is due to be discharged today.
 The patient first attended me yesterday evening
 On the next visit, Peter's condition had worsened and he was very anxious.
 Mr. Hauritz initially presented at my clinic on 20/11/09. At that time, examination revealed carious lesions on
several teeth along with poor dental hygiene.
 On review after three months, she had made good progress with her weight reduction.
 The patient was advised to reduce alcohol consumption, avoid heavy lifting and review in three months time.
 A review consultation was scheduled for one month later.

Example paragraph

Six months ago, Mr. Roberts twisted his right ankle while playing golf. During the following months, the patient
experience intermittent attacks of pain which hindered his ability to work effectively. On review after three months,
the right ankle joint was x-rayed and the result appeared to be satisfactory. However, when the swelling, pain and
impaired improvement persisted, an MRI was ordered which revealed a detached cartilage. Currently, Mr. Roberts
does not have full mobility, and is no longer capable of full-time employment on which, financially, his family depends.
Rules

 During + noun (underlined below)

Example: During his stay in hospital, Mr. Mason's condition has improved.

 When + time clause (underlined below)

Example: When Ms. Song returned today, she was pale and distressed.

 While + clause (underlined below)

Example: While waiting in reception, the patient fainted.

 Ago + past tense (underlined below)

The patient had a liver transplant 12 months ago.

Comma Placement
A comma is required when the time clause comes before the independent clause.

Handy Tip
Correct verb tense is an important point to consider when writing time clauses. The important points to remember are
as follows:
  When the verb of the time clause is in present form, the verb in the main clause must also be present or
future form.

Example: While you display symptoms of fever and rash, you are still infectious.

 When the verb of the time clause is in past form, the verb in the main clause must also be in past form.

Example: When the patient received his results, he fainted.

 When the verb in the main clause is in present perfect form, the verb of the time clause must be in present
perfect form.

Example: While the patient has been in hospital, his condition has steadily improved.

Incorrect Correct
 Today, the couple presented at my clinic. Mrs.  When the couple presented at my clinic today, Mrs.
Conway informed me that her home ovulation Conway informed me that her home ovulation
prediction test showed positive. prediction test showed positive.
 Today, when the couple presented at my clinic, Mrs.
Explanation: To demonstrate a higher level of English Conway informed me that her home ovulation
proficiency this information should be expressed in a prediction test showed positive.
complex sentence rather than two simple sentences.
 The patient has had placement of a prosthetic heart  The patient had placement of a prosthetic heart
valve 12 months ago. valve 12 months ago.
Explanation: has had is present perfect, but simple past is
required with the time marker ago.
 I first saw Mrs. Smythe at my clinic last week, she  When I first saw Mrs. Smythe at my clinic last week ,
urgently needed a new partial denture. she urgently needed a new partial denture. (best
choice)
Explanation: An adverb of time such as when required to  I first saw Mrs. Smythe at my clinic last week and
connect these two independent clauses she urgently needed a new partial denture.