N Shaffie1, L Cheng. 1. Oral, Maxillofacial, Head and Neck Surgery, Homerton University Hospital NHS Trust, London, UK. shaffie1@hotmail.co.uk
Abstract
INTRODUCTION: General referral letters to any hospital specialty are universally poor. These letters are the main source of information regarding the clinical problem and shortfalls can compromise the management of the patient. METHOD: One hundred retrospective randomly selected oral surgery referral letters in the form of proformae, made to oral and maxillofacial departments were examined against a set standard. Following the audit, a redesigned proforma, guidance and feedback questionnaires were distributed, followed by re-audit of 100 redesigned referral proformae. RESULTS: The main improvements seen were increases of: 52% in stating type of anaesthesia, 48% medical history, 38% referral date, 35% duration of symptoms, 32% use of the 'clinical details section', 31% stating treatment provided, 23% symptoms, 21% in clarity, 18% general medical practioner's (GMP's) address, 18% reason for referral, 15% social history, 14% diagnosis, 13% in using diagrams to aid explanation and 10% inclusion of a radiograph. DISCUSSION: Improvements in the quality of referral communications from local dentists were successfully made. CONCLUSION: Designing a pro-forma in close accordance with gold standards can achieve notable improvements to allow us to provide the best possible service and management for all our patients.
INTRODUCTION: General referral letters to any hospital specialty are universally poor. These letters are the main source of information regarding the clinical problem and shortfalls can compromise the management of the patient. METHOD: One hundred retrospective randomly selected oral surgery referral letters in the form of proformae, made to oral and maxillofacial departments were examined against a set standard. Following the audit, a redesigned proforma, guidance and feedback questionnaires were distributed, followed by re-audit of 100 redesigned referral proformae. RESULTS: The main improvements seen were increases of: 52% in stating type of anaesthesia, 48% medical history, 38% referral date, 35% duration of symptoms, 32% use of the 'clinical details section', 31% stating treatment provided, 23% symptoms, 21% in clarity, 18% general medical practioner's (GMP's) address, 18% reason for referral, 15% social history, 14% diagnosis, 13% in using diagrams to aid explanation and 10% inclusion of a radiograph. DISCUSSION: Improvements in the quality of referral communications from local dentists were successfully made. CONCLUSION: Designing a pro-forma in close accordance with gold standards can achieve notable improvements to allow us to provide the best possible service and management for all our patients.