TCF Writing gives you 45 minutes (5 to read the case notes, 40 to write) to produce one letter, usually a referral, for your own profession. A Grade B letter states its purpose in the first paragraph, includes only the case notes the reader needs, and fits in about 180 to 200 words. It is assessed against six criteria, and copying too much from the notes is the most common reason letters stay at C+. Below you will find a template to structure your letter and a worked example from case notes to a finished letter.
TCF Writing at a glance
| Detail | What to expect |
|---|---|
| Time | 5 minutes reading (no writing), then 40 minutes writing |
| Task | One letter from case notes, usually a referral |
| Other letter types | Transfer, discharge, or a letter to a patient or carer |
| Length guide | About 180 to 200 words in the body |
| Profession-specific? | Yes, the case notes are set for your profession |
| Criteria | 6: Purpose, Content, Conciseness and Clarity, Genre and Style, Organisation and Layout, Language |
The six criteria and what earns marks
| Criterion | What the assessor looks for |
|---|---|
| Purpose | The reason for writing is clear in the opening, and developed where needed |
| Content | The key information the reader needs is included, accurately, and irrelevant notes are left out |
| Conciseness and Clarity | Information is summarised well, and nothing distracts from the purpose |
| Genre and Style | The register suits the reader: technical for a colleague, plain English for a patient |
| Organisation and Layout | Information is grouped logically in paragraphs, in a clear letter format |
| Language | Grammar, vocabulary, spelling and punctuation are accurate and do not get in the way of meaning |
Purpose is marked on a 0 to 3 scale and the other five on 0 to 7, so every criterion matters. A fluent letter with the wrong content still falls short.
Use the 5-minute reading time well
- Read the task first. Who is the reader, and what do you want them to do? Everything else follows from that.
- Sort the notes into three groups: essential (the reader must know), useful (brief background) and irrelevant (leave out).
- Plan the paragraph order. Most relevant first: the current problem and what you need from the reader, then the history the reader needs to act.
TCF referral letter template
Use this structure for the layout and the job of each paragraph. Fill every [placeholder] with details from your own case notes, and change the wording to fit the case.
[Recipient's name]
[Recipient's position]
[Organisation]
[Street address]
[Town or city]
[Date from the task]
Re: [Patient's full name], DOB [date of birth]
Dear [Dr / Mr / Ms + surname],
Paragraph 1: purpose. I am writing to refer [Mr/Ms surname], a [age]-year-old [occupation or key context], for [assessment / management / review] of [main problem].
Paragraph 2: the current problem. [When and how they presented]. [Key findings the reader needs]. [What you have done or started].
Paragraph 3: relevant background. [History, medication and social factors that affect the reader's care, and nothing else].
Paragraph 4: the request. I would be grateful if you could [specific action you want from the reader]. [Any urgency or follow-up arrangement].
Please do not hesitate to contact me if you require any further information.
Yours sincerely,
[Your name]
[Your profession]
Worked example: from case notes to a Grade B letter
The task: you are a GP. Using the notes, write a letter of referral to Ms Laura Chen, Podiatrist, Riverside Community Podiatry Clinic, 14 Mill Road, Newtown, for assessment and management of the patient's foot ulcer.
- Patient: Robert Hayes, DOB 03/04/1968, warehouse supervisor, married, 2 adult children
- PMH: type 2 diabetes (12 yrs), appendectomy 1990, hypertension, well controlled
- Today: 2 cm ulcer over left 1st metatarsal head, noticed 3/52 ago; no cellulitis; reduced sensation both feet; weak left pedal pulses
- HbA1c 71 mmol/mol (last month); metformin increased today; wound swab sent
- Smoker, 15/day, declined cessation support previously
- On feet most of shift; wears old steel-toe safety boots
- Enjoys fishing at weekends; BP today 128/80
What to leave out, and why: the appendectomy, his family and his hobby do not affect foot ulcer care. Normal blood pressure and well-controlled hypertension are not needed either. His diabetes control, smoking, circulation, sensation and footwear all affect healing, so they stay.
Ms Laura Chen
Podiatrist
Riverside Community Podiatry Clinic
14 Mill Road
Newtown
16 September 2026
Re: Mr Robert Hayes, DOB 03/04/1968
Dear Ms Chen,
I am writing to refer Mr Hayes, a 58-year-old warehouse supervisor with type 2 diabetes, for urgent assessment and management of a non-healing ulcer on his left foot.
Mr Hayes presented today with a 2 cm ulcer over the left first metatarsal head, which he first noticed three weeks ago. There is no sign of spreading infection. However, sensation is reduced in both feet and his left pedal pulses are weak. A wound swab has been sent and I will forward the result.
He has had type 2 diabetes for 12 years, and it has been poorly controlled, with an HbA1c of 71 mmol/mol last month, so his metformin dose was increased today. He also smokes 15 cigarettes a day and has previously declined support to stop.
As Mr Hayes spends most of his shift on his feet in old steel-toe safety boots, I would be grateful if you could assess his footwear and offloading needs in addition to managing the wound. Given the risk of deterioration, I would appreciate it if he could be seen within the next week.
Please do not hesitate to contact me if you require any further information.
Yours sincerely,
Dr Sam Patel
General Practitioner
Why this letter works: the purpose and urgency are in the first sentence. Each paragraph has one job. Note-style fragments such as "reduced sensation both feet" are rewritten as full sentences. The request at the end is specific to the case, not a generic "please see and advise".
Mistakes that keep letters at C+
- Copying the notes in order. Case notes are in the order they were written, not the order the reader needs.
- Including everything. Normal findings, old resolved problems and irrelevant social details make the letter longer without helping the reader.
- A delayed or vague purpose. "I am writing regarding the above patient" does not say what you want.
- Note-style language. Fragments such as "BP 150/90, SOB on exertion" need to become full sentences.
- The wrong register. A letter to a patient's carer full of abbreviations and clinical terms misses the reader.
How to practise TCF Writing
- Write under the full 5 plus 40 minute timing from the start, including the no-writing reading time.
- Before writing, mark each case note as essential, useful or irrelevant, as in the example above.
- Get feedback per criterion. A single overall grade does not tell you what to fix.
Exam Hero grades your letter against all six TCF criteria in seconds, shows the case-note points you missed, and gives you a model answer. Try it free in the TCF question bank, and see the letter format and phrases guide for more wording options.
