What makes a good referral?

The art of writing a good referral letter can be a bit of a mine-field. As clinicians we all take pride in our work and when we are referring to another professional, usually an ophthalmologist we want to convey a sense of good clinical acumen and professionalism, and ultimately feel part of a respectful working relationship.

This is going to be one of these blogs where I’m afraid I can’t offer the magic wand that will suit every referral situation. However as someone who has experience of being the referrer from community practice, and someone who is receiving these letters in hospital and vetting them, hopefully I can offer some guidance which may be of help, particularly to our colleagues who are in pre-reg year or recently qualified.

Not long after I was qualified, I was working full-time in hospital, but also doing some Saturday locum days in practice. I can remember one day in the hospital clinic going into one of the consultant’s room to drop off a set of notes when he asked me to have a look at his patient’s optic discs to see what I thought. “These look pretty healthy and normal to me,” I said once I’d had a look. “Good…… in that case would you like to tell me why you referred him on the basis of suspicious discs,” was the reply from the consultant, with a bit of a wry smile. A great early lesson for me, to try to ensure that what I was referring was pretty water-tight as it could come back to bite me very easily! Another lesson I learn very early on was to only include concise and relevant information when writing up a case record or referral – I had a clinical mentor/lecturer at university who actively marked you down for including information that wasn’t clinically relevant. This was ideal from my perspective as I all but submitted a blank page with a patients name, date of birth and refraction one day, to come away with full marks!

From the optometry side of things, I can easily sympathise with the pressures at play. You are responsible for the patient and have the decision as to whether or not you need to pass that responsibility on or whether to monitor and review the patient in practice, all the time with the spectre of missing something lingering about in the background. This is a common scenario – you have had a ram-packed clinic, had to skip lunch, bent over backwards to keep patients happy, jumped through all the of hoops of the day, with one eye on the clock as you have to collect kids or make a train after work, and your 5.00pm patient requires a referral! Before you get out the door, you have to create something accurate and coherent by means of a referral, without the luxury of time to ponder  and fine-tune it. It’s not always easy!

In a typical week I vet around 30-40 referral letters to  the hospital, mainly for our cataract and glaucoma service. This activity is normally shoe-horned into spare minutes between patients or at lunchtime etc, and can be time-consuming. Thankfully where I work the standard is normally very good and the information clear. Nonetheless it can take time as you may have to look through previous records for a patient to get further information, so getting clear and straightforward information is really useful. The following are a few points I have come up with which I think can be of help:

Be concise

With a pile of referrals to wade through, you want to be pretty clear within the first sentence what the referral is for. This is really important as in a lot of departments the referrals may be divided up by clinical discipline, so if they can be easily identifiable, this is a big help. Think in general about the underlying reason for referral and only include information which is relevant to that main concern. Presenting this information in short points rather than a long paragraph can also help the reader get to the point quickly.

Legibility

The vast majority of letters nowadays are perfectly clear as a lot are electronically produced or typed rather than handwritten – but if they are handwritten, they must be clear (coming from me, this is a little bit of ‘people in glass houses I hasten to add!)

Include all relevant clinical information and images/plots

Having all the relevant information included first time is invaluable as it saves time requesting other items, such as a visual field plot on a glaucoma referral for example. Core information such as refraction and VA is always useful and relevant – particularly when glaucoma is concerned – refractive status is an important risk factor in several forms of this disease. It is always worthwhile having a pause between the initial writing of a letter and sending it, just in case there is any other information that you should include.

Make it clear if there is a degree of urgency attached to the referral

A lot of urgent referrals such as wet AMD will have a rapid access system in order to minimise the risk of delay, however for a lot of other situations where time is of the essence make this clear in the letter. At very least this helps grab the attention of whoever is doing the initial sift through the pile of letters. Obviously if it is a true emergency, this would be dealt with by phone call or fax.

Include your name and practice details

Occasionally I see letters where the referrer has signed the letter but written their name, which then makes it really difficult to write a letter back to the referring optometrist when seeing the patient in clinic. I am a huge advocate of writing back to the optometrist who has referred the patient, and also to keep updated. This is important both from a patient care perspective, but also good feedback for the optometrist.

Hopefully this brief review of the area of referrals has been useful. There is no one size fits all, as different areas will have different modalities of referral. However in general my take-home messages are, keep the information concise and to the point, making the main reason for referral clear from the start. Include all relevant information and leave out anything which doesn’t add anything of value, as this may just muddy the waters. Always have a read over the letter before sending and just ask yourself if there is anything else you need to include before sending. And finally include your details clearly  as this hopefully helps with two-way communication.

Thanks for reading!

Stan

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