海外への紹介状（診療情報提供書）の書き方

はじめに
サンプル
書き出し
本文
内服薬
締めの挨拶
終わりに

はじめに

日本人の方が海外に渡航する時や海外の方が一時的に日本で治療を受け母国に帰国する際など、紹介状を求められるケースが増えています。

紹介状は英語で、“Patient Referral Document” と言います。

日本語の表現をそのまま英訳しても、海外の医師には読みにくいため、紹介状の型を覚えておく必要があります。

急に言われて、手間取ってしまっても良くないので、ここで一例を出して解説していいます。

サンプル

まず以下にサンプルをしまします。早く書きたい方はこれを参考に穴埋めしてご利用ください。

Dear Dr. [Doctor’s Name],

Thank you very much for seeing Ms. [Patient’s Last Name].
The patient is a [Age]-year-old Japanese woman, who was seen in our clinic for [Diagnosis].
Her current condition is well controlled with the following medication.

She has been under my care since [Date]. She presented with symptoms of [Symptoms], which had been gradually worsening since [Date].
Upon evaluation, she was diagnosed with [Diagnosis]. I initiated treatment with [Drug Name], which has led to a significant improvement in her condition. She has been stable on this medication with no significant side effects.

Medications:
1. [Drug Name1 & Dose], once per day before bedtime
2. [Drug Name2 & Dose], per day before bedtime

I would greatly appreciate your assistance in providing Ms. [Patient’s Last Name] with the necessary medical care.
Please do not hesitate to contact me if you require any further information or clarification regarding her medical history or current treatment plan.

Sincerely,

[Your Name], MD

書き出し

まずは、患者の基本情報を伝えます。伝える内容は以下のことです。

名前
年齢
性別
診断・症状

・Thank you very much for seeing Mr./Ms. [Patient’s Last Name].

挨拶と患者の名前を紹介します。

・The patient is a [Age]-year-old man/woman, who was seen in our clinic for [Diagnosis].

年齢と診断を伝えます。

・The patient is a [Age]-year-old man/woman, who presented with [Symptoms].

診断名が明確でない場合は症状を伝えることもあります。

・His/Her current condition is well controlled with the following medication.

現在は安定していると伝えると良いでしょう。

Thank you very much for seeing Ms. [Patient’s Last Name].
The patient is a 24-year-old Japanese woman, who was seen in our clinic for Major Depressive Disorder.
Her current condition is well controlled with the following medication.

本文

本文で書く内容は、日本語と特に変わらないと思います。以下のような項目があると良いでしょう。

発症時期
症状の性質、程度
症状の経過（増悪、軽快）
治療内容

・He/She has been under my care since [Date].

・He/She presented to my clinic on [Date] with [Symptoms].

初診日の記載。

・He/She presented with [Symptoms], which had been gradually worsening since [Date].

発症時期とどのような症状があったかを書きます。

・Blood test showed [Lab values] and CT scan showed [Any findings].

精神科ではあまりないですが、何か検査所見があれば書くと良いでしょう。

・Upon evaluation, she was diagnosed with [Diagnosis].

診断名を書きます。

・I initiated treatment with [Drug name], which has led to a significant improvement in his/her condition.
He/She has been stable on this medication with no significant side effects.

・Treatment was begun with [Drug name]. His/Her symptoms has been well controlled with this treatment.

治療について書きます。治療の経過も記載すると良いでしょう。

She has been under my care since September 24, 2023. She presented with symptoms of depression, anxiety, and insomnia, which had been gradually worsening since July 2023.
Upon evaluation, she was diagnosed with mild depression. I initiated treatment with Sertraline, which has led to a significant improvement in her condition. She has been stable on this medication with no significant side effects.

内服薬

内服薬について別で書くと見やすいです。

Medications:
1. Sertraline 50mg, once per day before bedtime
2. Eszopiclone 2mg, per day before bedtime
3. Alprazolam 0.4mg, as needed for anxiety

締めの挨拶

・I would like appreciate it very much if you accept him/her under your care.

・I would greatly appreciate your assistance in providing Mr./Ms. [Patient’s Last Name] with the necessary medical care.

決まり文句になると思いますが、最後に患者の治療への協力をお願いします。

・Please do not hesitate to contact me if you require any further information or clarification regarding his/her medical history or current treatment plan.

このように必要時は連絡ください。と添えると丁寧でしょう。