Greys Hospital Audit of Outpatient Referral Letters January Purpose by lauraarden


									                           Greys Hospital
                 Audit of Outpatient Referral Letters
                                     January 2006

Purpose of the Audit
   1. The audit was undertaken because of complaints from referral institutions
      about the quality of referrals from Greys Hospital’s outpatients clinics
   2. It was felt that the quality of referrals could better be enhanced if the nature
      and quantity of the shortcomings was known

  1. A standard for filling of referral letters was drawn up based on the layout of
     the standard referral letter used by the Department of Health in Kwazulu-Natal
  2. A form was compiled using this standard and it was set out in the form of a
     score sheet
  3. 50 referral letters were gathered by the pharmacy at Greys Hospital
  4. Letters were given one (partially compliant) or two (compliant) marks for each
     criterion on the standard questionnaire
  5. Each letter was given a total score out of a possible maximum of 28
  6. A mean score was compiled for all the letters and expressed as a percentage
  7. Criteria were ranked according to degree of compliance

Reservations about the Audit
   1. Letters were all collected on one day (6 December 2005)
   2. A limited number of clinics and doctors were represented in the sample
   3. Questions included on information regarding the patient prior to consultation
      had to be excluded as all but one of the consultations were one way referrals
      down the system
   4. A clearer scoring system needs to be delineated
   5. There is a typographical error in the formatted referral letter which confuses
      the designation of the hospitals

Results of the Audit – Comment
   1. Patient Name (98%) – one file had only the surname of the patient
   2. Referral Institution (96%) – Greys Hospital not mentioned on two referral
   3. Date (92%) – Four letters were not dated
   4. Prescriptions (88%) – All letters had prescriptions, but some were illegible,
       sometimes because of faint copying
   5. Legible Script (87%) – Surprisingly good given the common wisdom about
       doctors’ handwriting
   6. Name of Referring Doctor (Legible) (83%) – Again surprisingly good, but it
       should be 100%
   7. Relevant Clinical Information (48%) – Something more than the diagnosis
       only was required to score more than 50%; some letters did not even contain a
   8. Contact Numbers (Telephone and Fax) (20%) – Only a telephone number on
       some of the letters; none had a fax number

   9. Name of Referring Institution (18%) – Clearly prescribers feel it is not their
       responsibility to designate the place where the patient is to receive follow up
       medications or care
   10. Information about follow up (16%) – Some referrals mentioned a time span to
       the next appointment but most said nothing about this
   11. Patient address (12%) – A few referrals referred to a town or suburb where the
       patient came from (eg “Northdale”) but only one had a street address
   12. Advice about Further Management (0%) – Many “referral” doctors don’t feel
       it is important to advise doctors at PHC or District Level how to continue to
       manage their patients, beyond writing a prescription

   1. The results and conclusions of the audit should be made available to doctors
      working in outpatients clinics at Greys Hospital
   2. Doctors must make an attempt to complete demographic and other details on
      the referral letter not directly related to patient care such as:
          a. The patient’s address
          b. Telephone and fax numbers of Greys Hospital
          c. Name of the referring institution
          d. The date
   3. Doctors must make sure that their prescriptions on the referral letters are clear
      and legible and that they penetrate to the bottom copy (write in ball point pen
      with the letter on top of the desk, not on top of another piece of paper)
   4. Doctors must take more trouble to complete clinical and laboratory details of a
      patient’s condition or conditions which may be relevant to follow up at the
      referring institution
   5. Doctors should consider including advice to caregivers at referring institutions
      about what to do in terms of follow up or further investigation and monitoring
      of patients referred “down the system”
   6. There need to be clear instructions in the referral letter about
      recommendations for follow-up and the next appointment
   7. Doctors must write legibly and those who have difficulty in doing this should
      consider receiving coaching to improve their handwriting
   8. The next audit of this nature needs to be refined on the basis of experience
      gained in this audit and the letters need to be collected in larger numbers
      (100), over a longer time span (a week) and from a wider variety of

Dr FJ Muller FRCPC


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