Enhancing continuity of information: Essential components of a referral document

Whitney Berta; Jan Barnsley; Jeff Bloom; Rhonda Cockerill; Dave Davis; Liisa Jaakkimainen; Anne Marie Mior; Yves Talbot; Eugene Vayda

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Missing essential component of a referral document
Gerald JM Tevaarwerk

Published on: 05 November 2008

Published on: (5 November 2008)
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Missing essential component of a referral document
Gerald JM Tevaarwerk, BA, MD, FRCPC Endocrinologist/Internist
During my 37 years as a consultant in Endocrinology and Internal Medicine, I have had few complaints about the information provided with requests for consultations. Nevertheless, your article provides me the opportunity to comment and suggest a further addition to your otherwise excellent proposed REFERRAL FOR CONSULTATION document.
Interestingly, the worst requests I receive now are nearly always from physicians usin...
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During my 37 years as a consultant in Endocrinology and Internal Medicine, I have had few complaints about the information provided with requests for consultations. Nevertheless, your article provides me the opportunity to comment and suggest a further addition to your otherwise excellent proposed REFERRAL FOR CONSULTATION document.
Interestingly, the worst requests I receive now are nearly always from physicians using an electronic medical record (EMR), frequently providing me with as many as 20 written pages, sometimes without a clear request for a specific consultation. What is missing in those requests, as well as in other consultation requests including your proposed document, is a concise summary or list of the past and present medical disorders, injuries, and past and current diagnostic and therapeutic interventions. Such a list forms the backbone of any patient's medical record, and is an essential instrument of communication.
A summary list can serve as the basis for the patient health record (PHR), may be provided to individual patients, and used for consultation requests. For those using an EMR, providing an electronic version of a summary list to the consultant can make the consultation more complete and the “write-up” easier to perform.
I have developed an excel-based electronic summary form for use in my practice that I would be happy to share with any interested readers.
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Competing Interests: None declared.