As well as the referral letter other stuff that comes under referral includes verbal and written communications with the patient and other health care profs allowing transfer of care based on your examination. The referral letters need to be complete, accurate and useful (clear concise and understood)
Info for the Px (verbal or written - both if poss)
- Reason for referral - diag, risk - "the pressure in your eye is a bit high so you might have glaucoma". Use technical term and description
- Expected Management - when, who, what
- Appropriate time course - when expected/followup, what to do if followup is missed
- Who is the patient - complete identification and contact deets - phone no. important if it's urgent
- Reason for ref - heading Re: , the key points, complete and concise relevant supporting info. brief history and test results if relevant. GOS18
- Identify Yourself - Name, posn, tel no, supervisor if pre-reg, stamp (esp if locum)
- What you expect/plan to do - recall/monitor/await discharge from hopital
- Authorisation - was verbal, signature best
- direct referral / shared care scheme
- ref to consultant via GP
- ref to optoms who specialize (keratoconus)
- 2.5% optoms no name on letter, 6% no postcode
- eg glaucoma - 85% give disc app, iop, field plot. which is good
- 80% good on the routine info - VA, refraction, symptoms, poor info on previous VA, fundus info, media, onset and duration of symptoms
- 57% no legible name, no practice address 7%
- Individual professionals - optoms, GPs, Other health care providers - health visiting nurses, physios, occupational therapists
- Screening programs - schools, special needs
- Informal - patient referrals (cos of your good rep - build the good rep and acknowledge this stuff!)
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