Welcome to question of the day #173

Eyetools question of the day #173

My boss in the practice who is also an eye specialist has conducted a review of some of my clinical records. She has told me that they are okay but that my referral letters are very poor. She gave me some tips but I’d like to improve my referrals as I know this is an important part of patient care. What can I do?

In my role as an expert witness, I see a lot of referral letters when I review patients’ notes as part of the medico-legal process. Sadly, these referral letters are often very poor. These are the commonly occurring faults:

  • Handwritten and impossible to read
  • Not dated
  • No date for the eye examination
  • Information on symptoms mixed up with information on signs
  • Use of standard jargon that a general practitioner would not understand
  • Use of non-standard jargon that no one would understand
  • The patient’s name and/or date of birth missing
  • Other information such as visual field print outs not attached.
  • Not clear whether the patient needs to be referred to a hospital specialist.

In the UK, in some areas, the local protocol is for a direct referral to hospital specialists with a copy of the referral letter being sent to the general practitioner. In other areas, all referrals other than emergency cases have to be set to the general practitioner for onward referral to a hospital-based eye specialist.

For my own continued professional development, I recently watched a video on referrals. One presenter was a hospital-based optometrist and the other a hospital-based ophthalmologist. The optometrist was responsible or reading all the referral letters and deciding which eye specialist the patient needed to see. They said that they always had plenty of poor referrals that made it very difficult to work out what the patient needed.

This is what they asked for in a referral letter:

  • Information that could be read, preferably typed
  • All patient and practice details and name of eye specialist referring
  • Include the patient’s telephone number
  • Clear indication if the appointment in the hospital was routine or urgent
  • A concise letter
  • Separate sections for symptoms and signs
  • Duration of signs and symptoms
  • Details of ocular history
  • Always include monocular visual acuities ever when referring for high intraocular pressure
  • A provisional diagnosis even if you have more than one condition in mind.

One of my current medico-legal cases involves glaucoma in a young man. His view is that his eye specialist did not tell him he might have glaucoma nor that he was being referred for further investigation. Certainly, there are no notes in the clinical records to indicate that the eye specialist told the patient about the possibility of glaucoma nor about being referred. The patient was referred, was sent an appointment letter from the hospital. He did know what it was for and didn’t attend. This resulted in a diagnosis of glaucoma being delayed by one year.

Write clear and concise referral letters, tell your patients about your suspicions and tell them that you are referring them. It’s in the patient’s best interests as well as yours.