8.7 Writing Letters and Reports: Contents
Content suggestions:
- Your qualifications and experience
- Clinical context. Source & reason for referral? Your role? Length of contact?
- Observations e.g. external signs of symptoms, or difficulty giving account
- Treatment provided and/or planned.
- Any conclusions e.g. about diagnosis, risk, capacity, prognosis
- Clinical factors that affect the person’s ability to give a coherent account
- Needs for further information e.g. expert evidence to document scars?
- Statement of truth and recognition of duty to the court