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 Table of Contents 
FAMILY MEDICINE PRACTICE
Year : 2013  |  Volume : 2  |  Issue : 2  |  Page : 145-148  

Structured printed referral letter (form letter); saves time and improves communication


Department of Family Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka

Date of Web Publication31-Aug-2013

Correspondence Address:
R.P.J.C. Ramanayake
Department of Family Medicine, Faculty of Medicine, University of Kelaniya, Ragama
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4863.117404

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  Abstract 

Referral of patients to hospitals, specialists and other institutions is an essential part of primary health care. Patients are referred to specialists when investigation or therapeutic options are exhausted in primary care or when opinion or advice is needed from them. Referral has considerable implications for patients, health care system and health care costs. Good communication between primary and secondary care is essential for the smooth running of any health care system. Referral and reply letters are the sole means of communication between doctors most of the time and breakdown in communication could lead to poor continuity of care, delayed diagnoses, polypharmacy, increased litigation risk and unnecessary testing. A referral letter also helps to avoid patient dissatisfaction and loss of confidence in family physician. Studies of referral letters have reported that specialists are dissatisfied with their quality and content. Inclusion of letter writing skills in the medical curriculum, peer assessment and feedback have shown to improve the quality of referral letters. . Form letters have shown to enhance information content and communication in referral process. In Sri Lanka referral letters are usually hand written and frequent complaints are that these letters do not contain adequate information and retrieval of information is a problem due to poor legibility and clarity. Sometimes Primary care doctors refer patients to hospitals and specialists with only verbal instructions. To address these short comings this form letter was introduced. Based on the guidelines and systematic review of published articles, items of information to be included were decided. Printed forms of the letter are kept in the practice and the doctor has to just fill up relevant information under each heading. The objectives of introducing this structured referral letter was to improve the quality and standard of referral letters and save time for both general practitioners and specialists.

Keywords: Referral letters, communications between GP and specialist, structured referral forms, general practice


How to cite this article:
Ramanayake R. Structured printed referral letter (form letter); saves time and improves communication. J Family Med Prim Care 2013;2:145-8

How to cite this URL:
Ramanayake R. Structured printed referral letter (form letter); saves time and improves communication. J Family Med Prim Care [serial online] 2013 [cited 2019 May 26];2:145-8. Available from: http://www.jfmpc.com/text.asp?2013/2/2/145/117404


  Introduction Top


Referral of patients to hospitals, specialists and other institutions is an essential part of primary health care. Patients are referred to specialists when investigation or therapeutic options are exhausted in primary care or when opinion or advice is needed from them. Indication for referral may be routine (cataract), urgent (iritis) or emergency (acute glaucoma). General practitioners/family physicians manage over 95% patient encounters on the average on their own but the remainder requires further resources and expertise. [1]

Idea behind referral is for two physicians with different experience and expertise to communicate with each other in finding a solution for a patient's problem and providing the best possible care at the correct time at the correct place. Referral has considerable implications for patients, health care system and health care costs. [2]

Karunarathna one of the pioneers of family medicine in Sri Lanka described primary care physicians as "doctors who have a large measure of expertise in breath unlimited by age, sex, body system or type of problem (physical/psychosocial) [1]" and referral as "an appreciation of the limitation of their expertise in depth. [1]" She has emphasized that in the process of referral primary and continuing responsibility for the patient should lie with the family physician who is best suited for maintaining continuity and coordination of care. [1]


  Communication Between Doctors Top


Good communication between primary and secondary care is essential for the smooth running of any health care system [3] and it is also vital for a safe and high quality referral process. Breakdown in communication could lead to poor continuity of care, delayed diagnoses, polypharmacy, increased litigation risk and unnecessary testing. [4] Communication between doctors of different experience and expertise is also an important means of education for both. [3]

Often there is no direct contact between primary care doctors and specialists. Even though methods of communication have significantly changed in the past few decades with the advent of mobile phones, internet, email etc., written communication in the form of referral and reply letters are the most common and most of the time sole means of communication between doctors. [5] In fact there is a general acceptance also that communication must be by letter. [6]


  Referral Letters Top


A clear and concise letter with sufficient information will aid the specialist and the patient in many ways. It prevents delays in diagnosis and treatment and reduces unnecessary repetition of investigations and poly pharmacy which will increase health care costs. [5] Such a letter also helps to avoid patient dissatisfaction and loss of confidence in family physician. [3] Apart from conveying information referral letters are a valuable source of reference, evidence of informed consent and a medico legal record. [7] Referral letter reflects the diagnostic skills, communication skills and professionalism of the doctor. [8] Number of studies have revealed an improvement of quality of reply with quality of referral letters. [4],[9]

Studies of referral letters have reported that specialists are dissatisfied with their quality and content. [5],[10] Several studies have revealed frequent absence of an explanation for referral, medical history, clinical findings, test results and details of prior treatment in referral letters. [11],[12],[13],[14] At the same time clarity, legibility and overall format are also important features of a good referral letter. Number of authors have mentioned time constraints [1],[4] and lack of secretarial support [3] as reasons for incomplete and badly written referral letters.

Attempts have been made to improve the quality of referrals. It has been suggested to include letter writing skills in the medical curriculum of both undergraduate and post graduate courses. [1],[15] Peer assessment and feedback have been identified to improve the quality of referral letters. [16] Several studies have reported the use of form letters to enhance information content and communication in referral from general practitioners to hospital and medical specialists. [17],[18],[19],[20],[21] Grimshaw, et al., reported that only structured referral sheets and involvement of consultants in educational activities would improve the effectiveness and efficiency of referrals from primary care to secondary care, following Cochrane data base review. [2]


  Form Referral letters Top


Form letters are structured or standardized referral letters which include headings for relevant information. Form letters have been found to be shorter and contain more information than non-form letters. [19] Couper and Henbest reported an improvement in the quality of referral letters after the introduction of a form letter [20] and a few studies revealed that general practitioners preferred structured letters. [18],[22],[23] Martin and others described the advantages of a structured format for referral and reply letters, which includes easy identification of information desired. [24]


  Scenario in Sri Lanka Top


Sri Lankan health system is such that referral from primary care to secondary care is not essential to consult a specialist. Patients are free to consult a specialist of their choice even for a minor ailment in the private sector. In Sri Lanka referral letters are usually hand written and frequent complaints are that these letters do not contain adequate information and retrieval of information is a problem due to poor legibility and clarity. Another scenario is that primary care doctors refer patients to hospitals and specialists with only verbal instructions perhaps due to time constrains. [1] Use of computers for record keeping or to generate prescriptions and letters is not common and popular among primary care doctors in Sri Lanka yet.


  Development of form letter Top


Based on the guidelines and systematic review of published articles, items of information to be included in the letter were decided. [1],[5],[7],[12],[13],[14],[25] Drawbacks of current referral process and referral letters were taken into account. Expectations of specialists regarding the quality of referral letters were also considered. [5],[10] To minimize the cost of printing, dimensions of the letter were decided so two letters can be printed with an A4 paper [Figure 1]. Printed forms of the letter are kept in the practice and the doctor has to just fill up relevant information pertaining to the patient under each heading. The main objective of introducing this structured referral letter was to improve the quality and standard of referral letters.
Figure 1: Referral form

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Advantages of the form letter

This form letter will be of advantage to general practitioners and recipients in many ways.

  • Saves time of the general practitioners

    It is not necessary to plan or think about the format of the letter. It is just filling up details pertaining to the patient.
  • Letter writing skills and competence in language are immaterial.
  • Legibility is not a major problem as in an unstructured letter
  • Clarity is better with the structured format.
  • Headings remind the information to be included and thus improve the completeness of information.
  • Can be used for any patient irrespective of the system involved (cardiovascular/dermatology/psychiatry), type of referral (routine/urgent/emergency) and intention of the referral(opinion/advice/investigations/treatment or admission)
  • Minimal cost
  • Facilitates research and audit
  • Saves time of the recipient

    Headings and structured format facilitate information retrieval.


This has been in use at the Family Medicine Clinic, Faculty of Medicine, University of Kelaniya which is a group practice and author's part time general practice in Sri Lanka for more than one year. Doctors who have used this letter have expressed positive views; "It saves time" "reminds information to be included" "looks professional".

 
  References Top

1.Karunarathna L De A. Consulting wisely-an art in family medicine. Sri Lankan Family Physician 1999;22:8-15.  Back to cited text no. 1
    
2.Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008;4:CD005471.  Back to cited text no. 2
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3.Westerman RF, Hull FM, Bezemer PD, Gort G. A study of communication between general practitioners and specialists. Br J Gen Pract 1990;40:445-9.  Back to cited text no. 3
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4.Tejal K, Michael F, Andrew JS, David GF, David WB. Communication breakdown in the outpatient referral process. J Gen Intern Med 2000;15:626-31.  Back to cited text no. 4
    
5.Francois J. Tool to assess the quality of consultation and referral request letters in family medicine. Can Fam Physician 2011;57:574-5.  Back to cited text no. 5
    
6.Long A, Atkins JB. Communications between General Practitioners and consultants. BMJ 1974;4:456-9.  Back to cited text no. 6
[PUBMED]    
7.Campbell B, Vanslembroek K, Whitehead E, van de Wauwer C, Eifell R, Wyatt M, et al. Views of doctors on clinical correspondence: Questionnaire survey and audit of content of letters. BMJ 2004;328:1060-1.  Back to cited text no. 7
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8.Keely E, Myers K, Dojeiji S, Campbell C. Peer assessment of outpatient consultation letters: Feasibility and Satisfaction. BMC Med Educ 2007;7:13-8.  Back to cited text no. 8
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9.Richard G, Noor RL, Leo VK, Hubb W, Henk M. Communication at the interface: Do better referral letters produce better consultant replies? Br J Gen Pract 2003;53;217-9.  Back to cited text no. 9
    
10.Ong SP, Lim LT, Barnsley L, Read R. General Practitioners' referral letters Do they meet the expectations of gastroenterologists and rheumatologists? Aust Fam Physician 2005;35:920-2.  Back to cited text no. 10
    
11.Newton J, Hutchinson A, Hayes V, McColl E, Mackee I, Holland C. Do clinicians tell each other enough? Analysis of referral communication in two specialties. Fam Pract 1994;11:15-20.  Back to cited text no. 11
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12.Hansen JP, Brown SE, Sullivan RJ, Muhlbaier LH. Factors related to an effective referral and consultation process. J Fam Pract 1982;15:651-6.  Back to cited text no. 12
    
13.Graham PH. Improving communication with specialists. The case of an oncology clinic. Med J Aust 1994;160:625-7.  Back to cited text no. 13
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14.Newton J, Eccles M, Hutchinson A. Communication between general practitioners and consultants. What should their letters contain? BMJ 1992;304:821-4.  Back to cited text no. 14
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15.Nestel D, Kidd J. Teaching and learning about written communications in a United Kingdom medical school. Educ Health (Abingdon) 2004;17:27-34.  Back to cited text no. 15
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16.Crossley GM, Howe A, Newble D, Jolly B, Davies HA. Sheffield assessment instrument for letters(SAIL): Performance assessment using outpatient letters. Med Educ 2001;35:1115-24.  Back to cited text no. 16
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17.Dupont C. Quality of referral letters. Lancet 2002;359:1701.  Back to cited text no. 17
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18.Rawal J, Barnett P, Lloyd BW. Use of structured letters to improve communications between hospital doctors and general practitioners. BMJ 1993;307:1044.  Back to cited text no. 18
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19.Jenkins S, Arroll B, Hawken S, Nicholson R. Referral letters: Are form letters better? Br J Gen Pract 1997;47:107-8.  Back to cited text no. 19
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20.Couper ID, Henbest RJ. The quality and relationship of referral and reply letters; the effect of introducing a pro-forma letter. S Afr Med J 1996;86:1540-2.  Back to cited text no. 20
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21.Jones NP, Lloyd IC, Kwartz J. General practitioner referrals to EYE Hospital: A standard referral form. J Royal Soc Med 1990;83:770-3.  Back to cited text no. 21
    
22.Jenkins RM. Quality of general practitioners referrals to outpatient departments: Assessment by specialists and a general practitioner. Br J Gen Pract 1993;43:111-3.  Back to cited text no. 22
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23.Ray S, Archbold RA, Preston S, Ranjadayalan K, Suliman A, Timmis AD. Computer-generated correspondence for patients attending an open-access chest pain clinic. J R Coll Physicians Lond 24. 1998;32:420-1.  Back to cited text no. 23
    
24.Tattersall MH, Butow PN, Brown JE, Thompson JF. Improving doctors' letters. Med J Aust 2002;177:516-20.  Back to cited text no. 24
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25.Simon C, Everitt H, Kendrick T. Telephone consultations, home visits and referral letters. Oxford handbook of General Practice. 2 nd ed. Oxford: Oxford University Press; 2006. p. 51.  Back to cited text no. 25
    


    Figures

  [Figure 1]


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