Assessment of Completeness of Documentation of Referral Papers and Reasons for Referral Among Referred Patients to Tash Ed.
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Date
2014-06
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Addis Ababa University
Abstract
INTRODUCTION: In the referral process, referral papers are the standard and typically the sole
method of communicating information between general practitioners and hospital specialists.
Sub-optimal referral letter can be a source of poor continuity of care (delayed diagnosis, multiple
medication, multi-drug resistance, high litigation risk, unnecessary testing and extra-medical
costs) and therefore, decrease the quality of care. Referral papers of high quality are an essential
part of good clinical care and act as the interface between health care professionals in primary,
secondary and tertiary care.
OBJECTIVE: The aim of this study is to assess the quality of documentation on referral papers
of patients referred to Tikur Anbessa Specialized Hospital Emergency adult, pediatrics and
gynecology and obstetrics departments.
METHODOLOGY: This study was conducted at TASH EDs from December- June 2014 by
implementing a retrospective cross sectional study design. A total of 1011 patient referral papers
were recruited by simple random sampling method. Data was collected from patients’ individual
folders retrospectively. For collecting relevant information, data was collected by using dummy
tables and analyzed using SPSS version 20.0.
RESULTS: All 1011 eligible referral letters from Tikur Anbessa Specialized Hospital
Emergency Department were systematically assessed in this study. The result shows that the
name of the patient featured in all of referral letter (100%, n=1011). Only 29.8% of referral
letters bearing the patient’s address while 70.3% of referral letters contain history of present
illness; 30.3% of referral letter contain physical examination and 19.4% of referral letters
contain all the vital signs. The histories of allergies were reflected in none of the referral
letters. About 12.2% referral letters were not entirely legible.
CONCLUSION: Most of the socio-demographic data except the address were documented in
the referral papers. The clinical information section (the most important part) of the referral
paper was strikingly deficient especially history of allergy, vital signs, physical examination
findings, chief complaint(s), results of basic investigations, treatment given. Only the working
diagnosis and reason for referral were documented in most referral papers. In a quarter of referral
papers assessed, the receiving unit was not mentioned, of which more than half wrote to any
hospital. Signature of the referring clinician rather than name or qualification was documented
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Keywords
Referred Patients