How to Write a Medical Release Letter

The scope of influence of the term ‘medical’ is more than simply administering disease control medication. The implications are much more. The whole gamut involving medial assistance and health care involves everyone from the security department to the deans. Among the many areas that call for attention lies the need for electronic medical records or hand-written documentation and accurate communication. Whether you are involved in a hospital discharge or admission or part of the medical fraternity, the need for written communication looms large. The fraternity stands on the pillars of trust and expertise, which can only be strengthened through dedicated communication. One of the many forms of accurate communication involved in delivering or receiving medical care is a medical release letter.

The medical release letter is designed to communicate release of a patient from one hospital segment to another or from one doctor to another. There are a number of sensitive issues involved, and naturally since miscommunication could be fatal. A medical release letter is designed and updated periodically to give the next facility or doctor an exact picture of the case study. Everyday, there are a variety of medical reports churned out of the offices of physicians, clinics and hospitals. The medical release letter would naturally have to contain specific information about the progress made in each work setting.

Features of a medical release letter: A medical release letter is a formal letter. The document is drafted in the most professional manner, encompassing all case related information. The medical release letter is supposed to offer detailed information on:

• Charted notes from the beginning with correct use of related medical abbreviations and terminology
• Reference letters and medical referrals
• Initial and subsequent office evaluations
• Case history documented via medical transcription
• Copies of communication on patient care rendered and subsequent physical examinations
• Consultation reports and communication evidence between facilitators, to avoid medical malpractice
• Lab reports on the case related medical tests and tools
• Summaries of discharge to and from various facilities, if more than one

The letter being a formal one should have the following features:

• Name and address of the previous medical facilitator, with complete contact details
• Highlighted subject that makes a quick scan through possible, especially in emergencies
• The date of issue, which is very important to any case study
• Detailed body format, describing diagnosis, treatment and observations
• Enclosed copies of department reports, progress notes and diagnostic studies
• Conclusion, describing the current status of the case

The medical release letter could be a single page or multiple pages and attachments. The general and widely accepted format follows the SOAP format: subjective, objective, assessment and plan. However, the use and reference to a medical release letter has changed and the term ‘medical release letter’ now also indicates communication from:

• Physicians to communicate patient information, post treatment
• Medical aid facilitators to other physicians
• Medical aid facilitators to companies handling medical insurance companies to assist medical billing claims
• Medical aid facilitators to government offices

The preferred format is ‘standard business letter’ or ‘specific letter’. Most medical aid facilitators prefer setting full or partial block formats, according to collective call. The medical release letter format could either be ‘left aligned’ or ‘centered’, depending on the preference of the issuing authorities. However, the ‘left aligned’ format is the most preferred the world over.