Analysis of referral letters – content
It is suggested that you look in detail at 10 consecutive acute referral letters you have written. The person to whom you have referred will be meeting the patient for the first time (usually) and a full patient history is important. The patient is likely to be acutely ill and you may be able to impart important information to the admitting doctor. Check the referral letters for the following details and if appropriate suggest changes. As an OOH GP you may not have access to all the information the patients own doctor would normally have and this may be an interesting point to reflect on. You may wish to include your reflections on the issues identified and learning points on MARS, and include your analysis as additional supporting documentation.
You may download a template here.
| Reason for referral | History of complaint | Medication history, allergies | Examination findings. | Relevant psychosocial history | Past medical history |
|---|---|---|---|---|---|
| Y | Y | Y | Y | N | N |
| Y | Y | N | Y | N | Y |
| Y | Y | Y | Y | N | N |
| Y | Y | Y | N | Y | Y |
| Y | Y | N | Y | Y | N |
| Y | Y | Y | N | N | N |
| Y | Y | N | Y | N | Y |
| Y | Y | Y | Y | Y | Y |
| Y | Y | N | Y | N | Y |
| Y | Y | Partial | Y | Y | Y |
Issues identified
When I looked at my referral letters I was quite happy that there was adequate evidence of reason for referral and a history of the presenting complaint in all letters examined. The medication history was reasonable in most but lacking in a few which could have been important. I was much worse at recording psychosocial and past medical history this is probably a reflection of not knowing the patient prior to the consultation. I would however perhaps be in a better position to obtain this information compared to the admitting doctor.
Learning points
My referral letters were sometimes of high quality but there was some scope for improvement, there was one in particular that contained insufficient information. The OOH service provides us with structured admission letters and I have simply been ignoring the headings and writing free hand. I will endeavour to “fill in the blanks” even with negative comments (e.g. no past medical history of note). I will re-examine this next year.