[Gnumed-devel] Quality referral requests

[Busser, Jim]

Hi all,

This posting is to explore in GNUmed how best to construct a referral letter 
that follows the appended suggestions from Canadian Family Physician May 2011 
vol. 57 no. 5 574-575.

I am thinking:

- parts of a progress note, combined with
- LaTex form for the demographics and "list" items
- and maybe something as part of free text going into the report (however, my 
preference is to have as much as possible inside GNUmed narrative).

Referring to the list at bottom, the sections could be achieved as

      1 (demographics) is automatic via placeholders
      2 (initial statement) ...
      … 5 (descriptions) -- the S in a single Soap entry
      6 (past medical history) == automatic via placeholders
      7 (past surgical history) == automatic via placeholders
      8 (relevant psychosocial history) ???
      9 (current medication list) == automatic via placeholders
      10 (allergies) == automatic via placeholders
      11(relevant clinical findings) <--- for 11-15, see comments below
      12 (results of investigations to date)
      13 (outline of management to date)
      14 (provisional diagnosis or clinical impression)
      15 (statement of what is expected from the referral)

In the 'S' of a SOAP row, despite that part of the content may be redundant, I 
am thinking it is reasonable to build, as distinct paragraphs

      2. Initial statement identifying the reason for the referral
      3. Description of chief complaint
      4. Description of associated symptoms
      5. Description of relevant collateral history

My uncertainty concerns how to factor each of the following:

        8 (relevant psychosocial history)

which, part of me thinks, should not be the entirety of what is known 
psychosocially about the patient, but rather what we think may be relevant to 
the referral. So perhaps even if there existed some place in GNUmed which 
stored a patient's place of birth, education, employment, financial, 
relationships, risks (smoking, alcohol, other substances), hobbies it can be 
important to not relay 100% of what is known.

      12 (results of investigations to date)

the above could be a paragraph inserted in the 'O' of a SOAP note (appended 
after the clinical findings). I realize people may wish to append a table of 
recent results to the report, but such a table might be an appendix to the 
consult. Separately from the "granular" results, there may some benefit from 
commentary as to what the referring doctor has identified of interest or of 
concern.

      13 (outline of management to date)

I am less sure where to out the above, because the following (14, 15) likely 
fit the soAp and soaP {A,P} respectively,

      14 (provisional diagnosis or clinical impression)
      15 (statement of what is expected from the referral)

I am also suspecting it may be easier to start a new encounter for the 
referral, than to be picking individual rows out from an encounter that 
contains a mixture of the visit and the referral, since the referral may need 
to contain information for more than one visit.

Thoughts?

        

      Consultation and Referral Request Letter Assessment Tool
        from: http://www.cfp.ca/content/57/5/574/T1.expansion.html

      Date of letter: ______________________________________
      Discipline letter directed to: ________________________
      
      A. Content
      1. Patient demographics
      2. Initial statement identifying the reason for the referral
      3. Description of chief complaint
      4. Description of associated symptoms
      5. Description of relevant collateral history
      6. Past medical history
      7. Past surgical history
      8. Relevant psychosocial history
      9. Current medication list
      10. Allergies
      11. Relevant clinical findings
      12. Results of investigations to date
      13. Outline of management to date
      14. Provisional diagnosis or clinical impression
      15. Statement of what is expected from the referral
      
      B. Style
      16. One topic per paragraph
      17. Paragraphs with fewer than 5 sentences
      18. One idea per sentence
      
      C. Overall appreciation by consultant (1 - 5)
        (1 = unhelpful … 5 = extremely helpful)
        1       2       3       4       5

Jim