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Patient results and instructions letter template

Australian documentation guide

A letter body for results and instructions already discussed or documented by the clinician. The actual patient, sender and contact details belong in the sending system.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Purpose of letter

Start with a simple reason for writing: which test or conversation this letter follows. Address the person directly if that suits the correspondence. Keep the opening calm and specific; a friendly greeting should not imply that a result is reassuring before the clinician has interpreted it.

Results summary

Name the test, its date and the result actually available. Explain abbreviations where their meaning is established. Keep reported, pending and unavailable results distinct. If the letter says a report is enclosed, check that the attachment is present.

What this means

Use the explanation the clinician gave, in words the person can understand. A result flag or reference range cannot supply that explanation on its own. Preserve uncertainty and any limits the clinician discussed rather than turning a finding into a diagnosis or an “all clear”.

Instructions

Set out the agreed actions in a useful order, with the timing that was actually stated. Explain who is arranging each step when known. Do not add a repeat test, treatment change or appointment interval because it seems like a usual next step. Required instructions that are missing stay [not stated].

Medications

Record only medicine advice the clinician documented. Keep established directions and any stated changes precise, even when the surrounding prose is conversational. Silence about medicines does not establish that the person should continue, stop or change them.

What to watch for

Include the clinician’s recorded safety advice: the symptoms or changes to notice, and what they told the person to do. Do not create a standard warning list from the result. If that advice is absent, leave [not stated] for review rather than inventing a reassuring substitute.

Next steps and contact

End with the agreed follow-up and a clear way to ask about the letter. Use verified practice or service details from the sending system. A planned call, booked appointment and completed conversation are different events; describe the one supported by the record.

Common omissions

Look for missing test dates, unexplained abbreviations, pending results and an action with no owner or timeframe. Note any communication support the person requested, such as an interpreter or written information, without assuming it has been arranged.

Review before sending

Read the letter as the person receiving it: can they follow the explanation and see what happens next? Confirm the clinical meaning, medicine directions and safety advice against the source. Check identifiers, contact details and enclosures, then follow the usual review and secure-sending process.

Worked examples

A result explained with an agreed follow-up

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

PURPOSE OF LETTER: Dear patient, this letter summarises the urine test and follow-up we discussed at your appointment.
RESULTS SUMMARY: The laboratory report dated 3 October states that no bacterial growth was detected. The GP reviewed that report with you today.
WHAT THIS MEANS: The GP explained that this test did not identify a bacterial cause for the symptoms you described. It does not explain every possible cause of those symptoms.
INSTRUCTIONS: As agreed with the GP, please attend the follow-up appointment booked for 7 October so you can discuss how the symptoms are going.
MEDICATIONS: The GP documented that no medicine was prescribed or changed at this visit.
WHAT TO WATCH FOR: The GP advised you to seek urgent assessment if you develop fever with flank pain or cannot pass urine. This is the advice recorded in the fictional encounter.
NEXT STEPS & CONTACT: Your follow-up appointment is booked for 7 October. Please use the practice's verified contact details, added in the sending system, if you need to discuss the letter or change the appointment.

A results letter that still needs the clinician's explanation

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

PURPOSE OF LETTER: Draft letter about blood tests collected on 2 October; the extract does not establish that the results have been discussed with the patient.
RESULTS SUMMARY: A laboratory report is listed in the record, but its results are not included in this extract.
WHAT THIS MEANS: [not stated]
INSTRUCTIONS: [not stated]
MEDICATIONS: [not stated]
WHAT TO WATCH FOR: [not stated]
NEXT STEPS & CONTACT: The practice is the intended contact. The agreed next step and verified contact details are not stated in this extract.

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.