The accuracy of medical history information in referral letters.
BACKGROUND
Accurate medical history information is essential for good patient care and should be notified in the letter of referral. The aim of this study was to investigate the subjective opinion that the medical information in a large number of referrals is either inaccurate or non-existent.


METHODS
Medical histories from 54 patients with positive medical history findings upon taking the medical history at the initial consultation appointment were compared to the medical information supplied in the referral letter.


RESULTS
Overall, medical information was only 58.8% complete with dental referrals being 55.2% complete and medical referrals 62.4%. The majority of referral letters (70.4%) missed at least one relevant finding and only 29.6% of referrals were 100% complete.


CONCLUSIONS
The results of this study suggest that the standard of referral letters needs to be improved as the received referrals were generally incomplete and contained inaccurate information. This highlights the need for each and every practitioner to take their own detailed medical history and not rely on the information supplied in the referral.
DeAngelis
A F
AF
Oral and Maxillofacial Unit, Royal Hobart Hospital, Tasmania, Australia. ADeAngelis1@gmail.com
Chambers
I G
IG
Hall
G M
GM
D002318:Cardiovascular Diseases / Q000145:classification; D015709:Correspondence as Topic; D003815:Dentists; D004164:Diphosphonates / Q000627:therapeutic use; D004342:Drug Hypersensitivity / Q000145:classification; D064420:Drug-Related Side Effects and Adverse Reactions; D005194:Family Practice; D005792:General Practice, Dental; D006474:Hemorrhagic Disorders / Q000145:classification; D006801:Humans; D008487:Medical History Taking / Q000592:standards*; D008511:Medicine; D010820:Physicians; D011331:Private Practice; D017150:Public Sector; D012017:Referral and Consultation / Q000592:standards*; D012140:Respiratory Tract Diseases / Q000145:classification; D011795:Surveys and Questionnaires; D014081:Tooth Extraction
D004164:Diphosphonates