Minimum essential elements for consultation letters
| MINIMUM ESSENTIAL ELEMENTS | LABEL IN FIGURE 1 | REASONS AND EXAMPLES |
|---|---|---|
| Patient’s (1) name, (2) date of birth, (3) contact information, and (4) OHIP number | Patient details | Identify patient, prevent medical errors, and ensure patient safety (Recommendation of expert panel) |
| Medical specialist’s (5) name and (6) contact information | Consultant details | Identify name and contact information of specific medical specialist who evaluated the patient10–12 |
| (7) Reason for the referral (as understood by the specialist) | Reason for referral as understood by specialist | State specific reason for referral, eg, “I saw Mr Jones, a 30-year-old man, for assessment after worsening of previously controlled asthma; also requested were medication recommendations and direct referral to CAE”13,14 |
| (8) Problem(s), as briefly identified by the referring physician or nurse practitioner | Specific problem(s) as identified by referring provider | Describe problem(s) that led to this referral, eg, “Healthy man with 10-y history of controlled asthma, recently experienced 2 emergency department visits in 10 d despite medication changes recommended by GP; patient is unable to control breathing and is using emergency inhaler daily; patient is unable to work owing to anxiety”6,11,13 |
| (9) Results of examination, tests, and procedures | Results of examination, tests, and procedures completed by specialist | Provide laboratory and investigation results for tests carried out by medical specialist; include results if available or identify if they are pending and, if so, how the referring provider can access them, eg, “Results March 22/07: CXR normal; PEF < 60%; routine bloodwork done here in my office within normal limits (copy of results included); no outstanding test results“6,15 |
| (10) Therapy proposed or initiated or the recommended treatment including all medications and their intended duration | All proposed treatments and medications | Itemize medication proposed or initiated by specialist; also identify medication discontinued by the specialist with reasons, eg, “Continue Ventolin 2 puffs QID; introduced LABA Serevent 2 puffs TID for 30 d until reassessed by specialist; continue using rescue breathing medication as per asthma action plan instructions”7,13,16,17 |
| (11) Problem(s), including answer(s) to specific question(s) posed by the referring provider | Answer(s) to specific question(s) posed by the referring provider | Eg, “Patient had not been taking routine Ventolin since March/07 and had recently started smoking again, both of which led to the recent exacerbation of symptoms”11 |
| (12) Primary or secondary diagnosis or problem | Primary and secondary diagnosis | Eg, “Exacerbation of controlled asthma” (Recommendation of expert panel) |
| (13) Plan of action developed for the patient OR management regimen (treatments or therapies proposed including medications) AND details regarding the specific verbal instructions or educational materials supplied to the patient | Signifies development of a plan of action for patient AND instructions and advice given to patient | Eg, “Provided patient a signed copy of asthma action plan, including clear instructions to take medication as prescribed, list of asthma medications, specific directions for medication changes when experiencing asthma symptoms, referral to CAE”7,18 |
| (14) Follow-up plan that specifies who is to do what and when. An important aspect is specifying who has been designated as responsible for the recommended actions (ie, patient, primary care provider, specialist, CAE, or another health care provider) | Follow-up plan recommended by specialist | Indicate follow-up arrangements booked or planned by the specialist’s office, eg, “Recheck appointment and repeat PFT to be done within 1 mo on or before May 1/07 at my office … appointment to be booked by patient” or “Appointment for initial assessment by CAE is to be booked for same day as specialist recheck appointment”11,16,18 |
| (15) Date prepared | Date prepared | Provide the date the consultation report was prepared (Recommendation of expert panel)12 |
CAE clinical asthma educator, CXR—chest x-ray, LABA—long-acting β2-agonist, OHIP—Ontario Health Insurance Plan, PEF—peak expiratory flow, PFT—peak flow test, QID—4 times daily, TID—3 times daily.