ASSESSMENT OF COMPLETENESS OF REFERAL PAPERS AMONG REFERRED PATIENTS TO SPHMMC

Abstract

Abstract INTRODUCTION: The referral system constitutes a key element of health system. Effective referral system between different levels of health care delivery represents a cornerstone in addressing patients health needs. 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: To assess the quality of documentation on referral papers of patients referred to SPHMMC paediatric department METHODOLOGY: A prospective institution based cross sectional was conducted among patients referred to SPHMMC from August 1 to 30, 2022, to determine the quality of referral paper. A total of 384 referral letters were recruited continuously during the study period until sample size fulfilled and data was entered and analysed by using SPSS version 25. RESULTS: Froma total 384 referral letters, 94.5% of the clinicians filled the demographic data (such as Name, Age, Sex, Address).Many of referral letters lacked important clinical information such as chief complaint (69.5%), P/E (60.7%), vital sign (47.9%). None of them addressed allergy history. 19.8% were not eligible CONCLUSION: There was good documentation of socio demographic information in nine out of ten assessed referral letters. Poor documentation of clinical information was seen in which only about one out of three referral letters contained clinical information of the patient. About nine out of ten documented administrative information, name and signature of referring clinicians but only half were mentioned their qualification. Reason for referral was documented in 96.6% of referral letters. From assessed referral papers 19.2% was eligible.