Sorry it has taken me so long to reply to this. I simply posted the question on the forum hoping others would chime in until I had time to respond. Looks like others read the question, but nobody wanted to leap in. I get it! It’s not an easy topic.
Basics:
Letterhead, Formal addressing, date…
Dear Dr. XYZ,
Re: ‘Doggy’ McDoggerson
Then, you want to structure it for the purpose:
Thank you for referring ‘Doggy McDoggerson’ (owned by Owner McDogerson) to NAME OF MY BUSINESS for physical rehabilitation. I just wanted to send you a quick note to let you know <my initial assessment findings and treatment plan> for ‘Doggy’.
(I personally like a casual feel to my ‘reports’. Alternately, you could write: “Please accept…” or “Please find below …” my assessment report and initial treatment plan for…)
(If this is a progress note, simply start with something like, “I just wanted to update you on the progress of ‘Doggy McDoggerson’.” If this is a discharge note, “I just wanted to send you my discharge summary for ‘Doggy McDoggerson’.”
Next:
The beginning of your report should review the facts.
‘Doggy’ first presented to the clinic on DATE, subsequent to INJURY/SURGERY/PROBLEM.
For an initial assessment:
On initial evaluation, I found… <Describe your findings as factually as you can. Do not use jargon or acronyms that a non-rehab vet would not know – i.e. ROM is not a common vet acronym, ‘tenderness’ is not used as in tender on palpation. You can say reduced range or pain on palpation.> You can sum up your findings if the dog wasn’t referred with a straight forward diagnosis (i.e. “Based on these findings, I suspect that ‘Doggy’ is suffering from…” or “Based on these findings my clinical impression is…” If it’s a straight forward injury / case (i.e. a post-op), you can jump right to the next part.
My problem list for ‘Doggy’ is as follows:
1. Reduced extension range in the left shoulder
2. Grade 2/4 lameness on the left front leg
3. Pain on palpation of the left supraspinatus tendon
4. Tight scapular musculature
<I believe that things are more readable and digestible if they are presented in point form and ‘choppy’ with just pertinent bits of info instead of long sentences.>
Then you could either include your goals – which would address each of these… but realistically, I don’t know that the referring vet cares, and quite frankly, the goals would simply be to improve upon the issues found. They don’t care about your timelines to address / correct the issues. So, I’d just jump into my treatment.
Treatment today consisted of laser therapy, stretches for the supraspinatus tendon, myofascial work on the scapular muscles and the creation of a home program. ‘Doggy’s’ home program consists of slow down hill walking, supraspinatus stretches, and 3-leg standing (lifting the unaffected forelimb). We have scheduled follow up appointments weekly for the next four weeks, where treatments may progress to include radial shockwave, electrical stimulation, advanced therapeutic exercises, and acupoints stimulation.
Then you finish up:
Thank you for the opportunity to work with ‘Doggy’ McDoggerson. Please feel free to call or e-mail if you have any questions.
Sincerely,
Signature
Name
ν --- ---
If you are writing a progress note:
You start with just: I just wanted to provide you an update on ‘Doggy’ McDoggerson.
‘Doggy’ has attended NAME OF YOUR PRACTICE since DATE, subsequent to INJURY / SURGERY / PROBLEM.
To date, ‘Doggy’ has received <X number of> treatments, consisting of <NAME THE TREATMENTS>.
Currently, on examination he is displaying… DESCRIBE HOW HE LOOKS NOW / YOUR FINDINGS. Additionally, his owner reports… HOPEFULLY YOU CAN SHARE SOME KIND OF IMPROVEMENT. (But if not, that’s okay… perhaps you are telling the vet that the dog is NOT making improvement.)
Currently, my plan is to… (continue working with ‘Doggy’ to progress his strength… endurance… reduce his pain… whatever.) My goal is to be able to discharge ‘Doggy’ in (time line… make a guess.) OR My goal is to transfer ‘Doggy’ to a maintenance program in <a month’s time… or whatever timeline> and check back on him every couple of months / monthly / quarterly… etc.
Please feel free to call if you have any questions.
Sincerely,
Signature
Name & letters
___
AND, if you are writing a discharge note:
Start with the discharge sentence:
I just wanted to send you my discharge summary for ‘Doggy’ McDoggerson.
Then it follows the same format as the progress note, only most of your findings and things to report are normal or mostly normal.
You can then state:
Doggy has been discharged from active rehabilitation. His owner has been instructed to call if ‘Doggy’ has a relapse of symptoms. (OR, perhaps you have set up a maintenance schedule. i.e. ‘Doggy’s’ owner is wishing to bring ‘Doggy’ in for maintenance visits on a quarterly basis for check-ups, tune-ups and massage (or whatever).
Thank you again for the opportunity to work with ‘Doggy’ McDoggerson. Please feel free to contact me if you have questions about this case or any others with which I could be of assistance.
Sincerely,
Signature
Name & letters
---
Phew, okay… I think that covers it for the most part.
I hope this helps!
All the best,
Laurie
