An Insight into the Referal Letters received at Pulmonology unit of a Tertiary Care Hospital

Hussain Ahmad, Syeda Nargis Jabeen, Afaq Rahim, Mukhtiar Zaman

Abstract


Background:Referrals letters are an integral part of multidisciplinary
approach to health care. Problems with quality and content of the referral
letters have been documented in literature. The objective of this study was to
study the content of referral letters received at Pulmonology unit of a tertiary
care hospital.
Materials and Methods:This was a prospective study of the referral letters
received at Pulmonology unit, Khyber teaching hospital Peshawar, from1 Feb
2016 till 30 April 2016. Patient's clinical information (brief history and examination), specific reason for referral, and identity of referring doctor
(name/designation) were considered minimum requirements of the referral
letters. The data was recorded in a structured proforma, analyzed via SPSS-19
and the results were presented as table or figures.
Results:A total of 164 referral letters written on patient's charts were analyzed.
Clinical history and examination was documented in 89.02% and
17.07% respectively, while specific reason for referral was mentioned in 42%
only. Main reasons for referral included diagnostic problem (4.89%), therapeutic
(37%), anesthesia fitness (12%), take over (10%), and interventions
including pleural biopsy (5.4%), chest intubations (9.1%) and bronchoscopy
(11.6%). Name of the referring doctor was missing in 87% of the letters.
Conclusion: There is a need to develop a standardized referral letter with
minimum essential information fields as the current referral practice needs
improvement


Keywords


Clinical Audit; Multidisciplinary Approach; Referral letters

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