Minimum essential elements for referral documents
| MINIMUM ESSENTIAL ELEMENTS | LABEL IN FIGURE 1 | REASON AND EXAMPLE | SUPPORT FROM REFERENCES AND LEVELS OF EVIDENCE* |
|---|---|---|---|
| (1) Patient’s name, (2) date of birth, (3) contact information, and (4) OHIP number | Patient details | Identify patient to avoid medical errors and ensure patient safety | Eliminates potential adverse events (Recommendation of the expert panel; level 6) |
| (5) Primary care provider’s name, (6) contact information, and (7) OHIP billing number | Referring provider details; Referring physician details (billing information) | Serves to associate referral letter with correct provider and ensures appropriate billing | Ensures appropriate billing as per OHIP billing guidelines8,9 (level 6) |
| (8) Problem(s) briefly identified by referring physician | Patient problem | Describe problem(s) that led to this referral, eg, Healthy male with a 10-y history of controlled asthma with 2 emergency department visits in the last 12 d despite medication changes | Improving content of referral letters is important; missing details affect patient care10 (level 5) |
| (9) Reason for referral, including (10) the specific question posed by referring care provider and (11) expectations of the consultant | Specific question and expectation of referral | State purpose of referral; specifically identify to consultant what you want or need, eg, Please see this patient for recent exacerbation of well-controlled asthma and offer suggestions for medications to maintain long-term control; consider for referral to the Clinical Asthma Educator in your clinic | Inclusion of specific questions and expectations enhances clarity and eliminates repeat consultations and subsequent overspending10,11 (level 5) |
| (12) Patient’s relevant medical history and (13) physical diagnosis, including (14) past and (15) current treatment | Past medical history Medication tried and discontinued | Give relevant information for diagnosis and include what you have already tried and what is currently being done, eg, PEF × 2 since recent visit to emergency; initial introduction of medium dose of ICS subsequently increased to maximum dose. Patient also using an updated Asthma Action Plan | Inclusion of relevant details eliminates redundancy12 (level 6) |
| (16) Patient’s current medications | Current medication | Itemize medications currently prescribed and already tried and discontinued that are relevant to the problem, eg, Ventolin 2 puffs QID × 10 y, introduced medium dose of ICS and LABAs × 7 d. After 2nd emergency visit, increased to maximum dose of ICS and LABAs with little improvement. No other medications | Advises of current medication and eliminates duplication10,13 (level 5) |
| (17) Laboratory tests and investigations including (18) pertinent laboratory findings | Recent laboratory and diagnostic results | Describe laboratory tests and investigations already conducted that are relevant to the problem, eg, Results March 22/07: CXR normal; PEF < 60%; all blood work within normal limits. See copy of results included | Limits duplication of procedures, reduces unnecessary resource use, and improves patient satisfaction14 (level 5) |
| (19) Details that patient is unable or unwilling to provide | Other relevant information (essential if patient is unreliable) | Apprise consultant of potential language barriers or patient’s limited understanding of the problem, eg, Patient speaks Spanish, has only limited English, and has no family or friends to translate | Important for understanding patient or enlisting assistance of an interpreter and elucidating relevant details that the patient cannot convey10 (level 5) |
| (20) List of suspected predisposing factors or triggers | Other relevant information (essential if important to diagnosis) | Identify known or suspected predisposing factors or triggers, eg, Indoor: dust mites, mold spores; outdoor: ragweed, grass, and mold spores | High-quality criteria for asthma referral13 (level 5) |
| (21) Verbal instructions or educational materials supplied to patient to date | Other relevant information (essential if related to question posed by referring provider) | Identify any instruction offered to patient to date and need for (further) education, eg, Patient might need instruction on inhaler technique or use of peak flow meter; has not received any education since initial diagnosis 10 y ago | Enhances informational continuity, limits redundancy and ensures patient-centred approach (Recommendation of the expert panel; level 6) |
| (22) Whether new referral or re-referral | Type of referral | Identify need for further medical investigation for new question or concern, or reinvestigation if initial question not adequately answered during first consult, eg, Patient referred to you in 1997 for diagnosis of asthma. This is a new referral for evaluation of asthma exacerbation | Re-referrals are useful when referring physician’s questions were not answered during first consultation or when patient has been referred before for a related problem but the questions or concerns are new; identifies appropriate referral and resource use14 (level 5) |
| (23) Level of urgency | Level of urgency | Denotes level of concern of referring physician, eg, Please see ASAP as patient is currently on maximum doses of corticosteroid medications and has had 2 emergency visits in 12 d | Ensures appropriate waits for urgent cases and offers suitable appointments for simpler requests (Recommendation of the expert panel; level 6) |
| (24) Date prepared | Date prepared | Provide date referral for consultation was prepared | Facilitates tracking and timely coordination of care; prevents gaps in care; improves wait times; provides a follow-up mechanism (Recommendation of the expert panel; level 6) |
CXR—chest radiography, ICS—inhaled corticosteroid, LABA—long-acting β2-agonists, OHIP—Ontario Hospital Insurance Plan, PEF—peak expiratory flow, QID—4 times daily.
↵* Levels of evidence related to outcomes: Level 5 evidence comes from descriptive clinical studies and can be useful in studying how to apply a new technique and identify the problems associated with it and how it works with various groups of patients. Level 6, the weakest type of evidence, is based on the opinion of respected authorities or expert committees without additional data.7