GP referral letters: time for a template?

Malta medical journal

Ronnie Farrugia¹  Karen Chetcuti¹  Kevin Cassar¹ 

关键词: referral and consultation;    family physicians;    outpatient clinic;   

DOI  :  

学科分类：医学（综合）

来源: University of Malta * Medical School

【 摘 要 】

Introduction: Referral of patients to the vascular clinic at Mater Dei Hospital by general practitioners requires the completion of the standard ticket of referral provided by the Department of Health (Form No DH22). The same form is used for referral to all clinics and all specialties and has remained unchanged for many years. The aim of this study was to assess the quality of information provided by the general practitioners completing the ticket of referral for patients referred to the vascular clinic.Methods: The referral tickets for 100 consecutive patients referred to the vascular clinic at Mater Dei Hospital between December 2007 and February 2008 were prospectively analysed. The referral tickets were assessed for completion of patient’s name, identity card number, address and telephone number. The tickets were also assessed for completion of the referring doctor’s name, registration number and address.Data were also collected on whether the indication for referral was stated and on whether relevant information was provided about risk factors for arterial disease and drug history. The referral tickets were also assessed as to whether the GP had commented on examination of pulses, and on advice given on smoking or exercise. Finally data were collected on whether the referral ticket was written, typed or printed and the legibilityof the document.Results: The only data that were complete in all 100 referral tickets was the patient’s name. In 9% of cases there was no identity card number, in 13% no patient address and in 64% no patient telephone number provided. In 22% of referral tickets the referring doctor’s name was not included and the registrationnumber of the referring doctor was only given in 34% of referrals. In 62% of cases no GP address was provided. In 16% of cases the indication for referral was not filled in. Information about diabetes, hypertension, hypercholesterolemia and cigarette smoking was only given in 46%, 28%, 15% and 20% respectively. In 60% of cases no mention of peripheral pulses was made. A comment about advice given to the patient regarding smoking cessation and exercise was made in 1% and 2% of cases respectively. 30% of referral tickets were only partly legible.Conclusion: The quality of completion of referral tickets by general practitioners to the vascular clinic is poor. Essential patient and doctor information is frequently lacking or incomplete. Basic relevant information regarding patient risk factors and examination findings is often missing. The use of a standard referral ticket for all specialties and the design of the current referral ticket probably contribute to the poor quality of completion of these forms.

【 授权许可】

Unknown