The amount of information required depends on the problem. A simple problem such as a skin lesion needs less information.
Introduce the patient to the consultant, giving their age and occupation if relevant and any other useful personal information.
Give a detailed account of the current problem including its site, its duration, severity and constancy and whether there are any associated symptoms. In the case of pain, any radiation to other areas should also be mentioned. In the case of a psychiatric referral, inclusion of a short mental state assessment may be helpful.
Detail examination of the relevant area of the body and note any more extensive examination.
Outline the results of any investigations undertaken.
Include relevant past medical history and any regular medication. In patients with complicated medical problems, it may be appropriate to include a summary of the patient’s full medical record.
Outline any particular concerns the patient has, as well as any information you have already given them about the diagnosis. The letter should close with thanks for the consultant’s opinion.