Writing the FSP medical note: structure, language, mistakes

BLÄK names documentation as the second exam part with a focus on medical professional language. At its core, the Arztbrief is a translation task: what you heard verbally in the conversation must be written down structured, correctly, and legibly for someone else.

A proven structure follows: salutation and subject, diagnosis/diagnoses, history, findings, course, therapy/procedure, closing. This order is not an official rule, but a convention that ensures readability for other doctors.

Patient statements are translated into reported speech: 'I have been dizzy for three days' becomes 'The patient reports dizziness for three days'. Every sentence should have a clear reference – who, since when, with what relevance – otherwise the letter becomes hard for others to follow.

• Write the structure first, then polish the language.
• Check every paragraph: is the reference unambiguous for someone else?

One misunderstanding: an Arztbrief must contain every detail from the conversation. In fact, medical relevance matters more than completeness at any cost. A second: the subjunctive is just a grammatical nicety – used incorrectly, it changes who is responsible for a statement.

Right after your next practised history-taking, write an Arztbrief within the allotted time and then check specifically: structure, reported speech, clear references.