Tool to assess the quality of consultation and referral request letters in family medicine

Reprinted with permission of the author, Dr. José François

 

Table 1:  A tool to assess the quality of consultation and referral request letters

Consultation and Referral Request Letter Assessment Tool

Date of letter:

Discipline letter directed to:

 

A. Content

1. Patient demographics

YES

NO

2. Initial statement identifying the reason for the referral

YES

NO

3. Description of chief complaint

YES

NO

4. Description of associated symptoms

YES

NO

5. Description of relevant collateral history

YES

NO

6. Past medical history

YES

NO

7. Past surgical history

YES

NO

8. Relevant psychosocial history

YES

NO

9. Current medication list

YES

NO

10. Allergies

YES

NO

11. Relevant clinical findings

YES

NO

12. Results of investigations to date

YES

NO

13. Outline of management to date

YES

NO

14. Provisional diagnosis or clinical impression

YES

NO

15. Statement of what is expected from the referral

YES

NO

B. Style

16. One topic per paragraph

YES

NO

17. Paragraphs with fewer than 5 sentences

YES

NO

18. One idea per sentence

YES

NO

C. Overall appreciation

Letter unhelpful to consultant

Informative helpful letter

1

2

3

4

5

         

 

The full article can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093595/

The author, Dr. José François, MD M Med Ed CCFP is Associate Dean of Continuing Professional Development and Associate Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg.

Correspondence: Dr José François, Faculty of Medicine, University of Manitoba, S03-750 Bannatyne Ave, Winnipeg, MB; telephone 204 789-3237; fax 204 789-3911; e-mail

 

2Ascribe Inc. is a medical transcription services agency located in Toronto, Ontario Canada, providing medical transcription services to physicians, clinics and healthcare providers across Canada and the US.  Having recently introduced WEBscribe, a client interface portal for document management, 2Ascribe continues to implement and develop technology to assist and improve the transcription process for physicians and other healthcare providers.  As a service to our clients and the healthcare industry, 2Ascribe offers articles of interest to physicians and other healthcare professionals, medical transcriptionists and office staff, as well as of general interest.  Additional articles may be found at http://www.2ascribe.com

 

 

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