Common mistakes made on referral letters:

1. Always use professional language.  Do not have colloquial written form.
2. Always include pertinent information.
3. Trade name of drugs must be capitalized; generic names of drugs are not capitalized.
4. Spelling – when a word is underlined in red, the library does not recognize it; if you don’t know if it is spelled correctly, then go to google for a correct spelling. Once you know a spelling is absolutely correct, highlight that word in your document, right click to drop down the spelling menue and click on “learn” so that this word is now in your SpecVet library (take note that this only affects your login profile and does not change spelling globally in SpecVet).
5. Forelimb; hind limb – take note of correct spelling…one is two words and the other is one word.  You may also use “thoracic limb” and “pelvic limb”
6. Salutation – needs to have the rDVM name; do not leave as “the veterinary clinic name”; if you cannot find the name, at least use “Dear Doctors” as your salutation.  Salutation should not include the first name of the doctor.  If it appears, please delete the first name in the salutation.  If this is present, it is because the original salutation was set up incorrectly (please notify Dr. Dan or David about this and one of them will correct it).
7. Left and right limbs are incorrect as to the limb with lameness or limb that needs surgery. Pay attention to detail to prevent the incorrect limb from being operated!
8. Plurality of terms – acetabulae not acetabulums; patellae not patellas; tibiae not tibias etc.
9. It is illegal to have abbreviations in medical records unless you have an abbreviation legend within the letter or full word(s) being abbreviated in parenthesis the first time they are used.
10. Issues that a dog may have that are completely forgotten to be mentioned.  Example dog comes in for a TPLO, but also a mass that is significant or was removed.
11. Grade of patellar luxation or cranial drawer – do not put mild, moderate severe, give an actual number (1 to 4/4). Do not type “None” for a grade.  If there is no patellar luxation, the grade is 0/4.
12. Joint range of motion – give a degree of ROM, like a number, not mild or good as this is too subjective. Does good ROM mean normal or just “good enough” for the pet to be functional.
13. Don’t write in incomplete or fragmented sentences. When fragments are appropriate (i. e. one or two words), do not use periods as these are not sentences
14. If there were previous radiographs from the rDVM, the interpretative findings must be included in the rDVM letter (or the summary from the radiologist’s report); don’t just mention that they were available for review; this should appear in the history as these are historical radiographs.
15. A numeric should not be used at the beginning of a sentence.  Always spell it out. (example: “Ten days elapsed….. “ not “10 days elapsed….”).
16. Do not call a referring veterinarian a “normal veterinarian”.  Call them the “primary care veterinarian”.
17. Keep capitalization consistent after each heading – either capitalize or do not at all. First word in sentences must always be capitalized.
18. If the case was sent over from an ER hospital, make sure that you also find out who the primary care vet is so that the letter will get to them too.  Put the primary care vet as the first and carbon copy the emergency from which it was referred.  This should be adjusted in the patient profile so that subsequent letters that are created will include both veterinarians in proper order.
19. Use appropriate anatomic orientations such as proximal, distal, medial, lateral etc.  Do not use terms such as “top, upper, bottom, lower, front, back, end” to describe a location on limb or face or anywhere on the body etc.
20. Always reference a limb as forelimb, thoracic limb, pelvic limb or hind limb.  Always notate if the limb is left or right.  Do not just state “the operated limb”.
21. Do not refer in the letter as “Dr. Degner will be evaluating the patient again in 2 weeks” if Dr. Degner is the clinician on the letter.  It should  be “ I will be evaluating the patient

 again in 2 weeks”. 

• Details on surgery reports are not accurate.  Template of the surgery report must be modified in detail to reflect what was done during surgery including details of suture patterns and suture types.