How do you dictate a medical letter?

To dictate a medical letter, decide the order of the letter before you speak, then dictate it section by section with the formatting commands your software supports. A practical order for most letters is: who the patient is, who the letter goes to, why you are writing, what you found, what happens next, and who receives a copy. Dictating in that order makes the draft easier to check and easier for a transcriptionist to format. Our guide to medical dictation explains the wider workflow.

Plan the order before you speak

Most of the work is in the planning. In an IBM study of letter composition, about two-thirds of the time spent composing a letter was planning, whether the letter was written, dictated or spoken ¹. So decide the order before you speak.

Dictating is a skill you can learn quickly. In the same study, novice dictators could learn in a few hours to dictate letters as fast and as well as they wrote them, although they did not think they performed that well ². The study used a recorder, not speech recognition software.

Dictate the letter in this order

1. Identify the patient and the date. Say the patient's full name, date of birth and record number, then the date of the letter. Use the identifiers your practice uses, and check them against the chart.
2. Name the recipient. Give the receiving clinician's name, practice and address. For a referral, state who referred the patient and why.
3. State the reason for writing in one or two sentences. The reader should know the purpose before reading the details.
4. Dictate the clinical content in short paragraphs. Cover the history, examination, results and your assessment, one topic per paragraph.
5. Give the plan. State what you are asking the recipient to do, what you have arranged, and what you will do next.
6. Close and sign. Dictate the closing, your name and credentials, and any copy recipients the letter should go to.

Your practice's template may use different headings. A template is the right answer where one exists, because it keeps every letter in the same order.

Say the formatting commands your software supports

Formatting commands differ by product, so check your software's list before you rely on it. On a Mac running macOS 27, Apple's commands include "new line", which starts a new line, and "new paragraph", which starts a new paragraph ³. Saying "new line" is equivalent to pressing Return once, and "new paragraph" is equivalent to pressing it twice ⁴. Two cautions apply. On a Mac, the new line or paragraph you say appears when you finish dictating, not as you speak ⁵, so review the layout at the end. And a command you do not say is a word the software may type, so dictate punctuation explicitly.

Save the standard parts as templates

The parts of a letter that never change are the best candidates for a template. In Dragon Medical One, saying "make that an auto-text" turns the selected text into an auto-text template ⁶. Use templates for the closing, the copy list and the standard paragraph about follow-up, and keep the clinical content dictated fresh each time. Our glossary entry on dictation templates explains the idea, and the question on medical dictation examples shows the format of finished reports.

Check who receives the letter

Sending a letter is a disclosure, and the reason you may send it matters. HIPAA permits a covered entity to use or disclose protected health information for its own treatment ⁷. That is the permission clinicians rely on when they document care. A letter to someone outside your treatment, such as an employer, may need a different basis. This guide does not give legal advice on which one applies. Before you send, check that the recipient is one you are permitted to send it to, and that the copy list matches that decision.

If you are not sure a copy belongs on the list, leave it off and ask. The glossary entry on the business associate agreement explains the contracts that apply when a vendor handles the letter.

It depends on your setting and your transcription workflow

• Dictating into the chart. If the letter is typed into the record as you speak, you review and correct it yourself, and the template matters most.
• Dictating to a transcriptionist. The transcriptionist formats the letter from your recording, so state the headings and copy list clearly. Our question on how to become a medical transcriptionist explains that role.
• Using an AI scribe. The draft is written from the visit, so check that the reason for writing and the plan match what you intended.

The workflow has changed over the decades, but the reader still needs the same things: the reason, the findings and the next step.

Review before you sign

Read the draft against the order above. Check the identifiers, the recipient, the medications, and the plan. Look for any sentence that does not sound like you, because recognition errors often sound plausible. Only sign a letter you have read in full.