Guideline 31: Report on a Recommended Referral Document

Report on a Recommended Referral Document
Section 1: Introduction

1.1 Background

Referral letters of high quality are an essential part of good clinical care.

The general practitioner is the gatekeeper to secondary care and is charged with the decision when to refer a patient and to whom the referral should be made. By implication, the general practitioner also has a role in the efficient delivery of health care within the National Health Service. Following the decision to refer a patient to a professional working in the secondary care environment, there is usually a written communication sent from primary care.

1.2 Aims of the referral document

Referral letters are a flexible means of transferring information between health professionals, as they can be adapted in form and content to cover both straightforward and complex clinical cases. In addition to this function, it is acknowledged that the referral letter can be used as a tool for clinical audit.

Good quality referral letters are an essential part of good clinical care and act as the interface between health care professionals in primary and secondary care. As such they have a number of functions: the referral letter provides patient information, which will include demographic details, as well as clinical information relating to the reason for the referral decision. In addition, the referring professional may choose to include information which would be otherwise unavailable to the receiving health professional. The referral letter is also used by medical records, appointments and clinic staff and necessarily includes a significant amount of administrative information.

1.3 The need for a recommended referral document

The referral letter is usually written following a consultation between the patient and the general practitioner. This usually takes place in the GP surgery but the letter may have to be written in the emergency setting, such as in a patient's home when urgent admission is required. In either case, adequate clinical information is essential to allow the secondary care professional to assess clinical need and urgency. In the referral process, letters are the standard-and typically the sole-method of communicating information between general practitioners and hospital specialists. These letters have been the subject of comment for many years: written communication between primary care practitioners and secondary care specialists is often haphazard and lacking consistency of content. While this may have improved over the last 10 years, evidence remains to suggest that the quality of written communication could be improved.^{1, 2,
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Following publication of the Scottish Intercollegiate Guidelines Network (SIGN) recommended minimum dataset for the immediate discharge document,¹⁵ SIGN established a multidisciplinary working group to review the published evidence and examples of good practice and make recommendations on a minimum essential dataset for communication from primary to secondary care. Although, by the nature of the subject, the majority of the evidence comes from non-experimental descriptive studies and expert opinion, the recommendations in this report should be regarded as being based on the best available evidence to date (see section 2).

The recommended referral document is designed primarily for general practitioner referrals, but it is intended to be suitable, with appropriate modification, for use by professions allied to medicine. The working group considered the information necessary for both routine/elective referrals and referrals made in an emergency or acute situation, and has made recommendations accordingly.

1.4 Mode of communication

Although a typed referral letter sent by conventional postal services or an internal hospital mailing system is the traditional method of conveying information from the referring doctor to the receiving doctor, it may be that, with emerging technologies, other forms of communication will become acceptable, e.g. fax and electronic mail. Using electronic communication, there may be no requirement for information inputted by primary care staff to be re-inputted by staff in the secondary care setting. This is the principle of single data entry.

The SIGN working group has tried to take account of new methods of transferring information such as the NHSnet or other electronic mailing systems. As a supporting initiative, the Information Management & Technology division of the NHS Management Executive have commissioned the development of an electronic version of the recommended referral document, designed to be compatible with most standard GP computer systems (see section 3).

For the purposes of this report, the "referral letter" should be seen as equivalent to the "referral document" or other method of transferring information between professionals. Irrespective of the method of transferring information, the information content will remain the same.