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 |
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|
Date of letter: |
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|
Discipline letter directed to: |
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|
A. Content |
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1. Patient demographics |
YES |
NO |
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|
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 |
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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 |
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|
11. Relevant clinical findings |
YES |
NO |
||
|
12. Results of investigations to date |
YES |
NO |
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|
13. Outline of management to date |
YES |
NO |
||
|
14. Provisional diagnosis or clinical impression |
YES |
NO |
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|
15. Statement of what is expected from the referral |
YES |
NO |
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|
B. Style |
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16. One topic per paragraph |
YES |
NO |
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|
17. Paragraphs with fewer than 5 sentences |
YES |
NO |
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|
18. One idea per sentence |
YES |
NO |
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|
C. Overall appreciation |
||||
|
Letter unhelpful to consultant |
Informative helpful letter |
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|
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.
