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Table 1 Plain language discharge letter assessment format and rubric

From: Teaching plain language to medical students: improving communication with disadvantaged patients

 

Hospital

Department

Letter Attributes

Number of sentences

Number of Words

Patient’s Data

Number of medications listed in the letter

Background diseases (list)

Admission diagnoses

Give a summary score on a likert scale of 1–5

 1. Telling the narrative of the hospital admission [1 …….5]

• Providing the narrative in a logical and helpful order starting with the most important ideas

• Describing the main hospitalization phases from admission to discharge

• Writing the narrative in an engaging way

• Thoughtful inclusion or omitting of medical information to the narrative

• Ending with clear guidance as to what the patient needs to do now

• Combining patient education, explaining results’ meaning and treatment rationale

 2. Adequacy and clarity of medical terms [1…….5]

• Good, simple correct explanation of medical and technical terms in a readable manner

• Logical description of history, physical examination, and investigations, and why they were done

• Avoiding expressions that could be misunderstood by lay people

 3. Language and style [1…….5]

• Written to the patient (or parent) in the active tense, respectful and not condescending

• Written in full sentences using sub-headings when the letter is long

• Using short sentences / avoiding long and complex sentences.

• No inappropriate phrases (offensive or expressing disrespect)

• Inclusion of useful diagram if helpful

 4. Medical problems list [1…….5]

• A complete list of medical problems, including chronic diseases

• The current problem, admission diagnosis - at the top of the list

 5. Medication Table [1…….5]

• Adherence to the medication table guidelines

 ○ Nam

 ○ Concise explanation of action

 ○ Dosage and administration instructions

 6. Instructions [1…….5]

• Clear and specific (what to do, when and where)

• Providing explanation for referrals and follow up in the community