With medical transcription outsourcing, doctors and hospitals are now able to streamline their functioning better. Such EHR-compliant solutions can help physicians and specialists to focus more on rendering care, which does improve overall patient satisfaction.
Outsourcing is important in the healthcare field since doctors are highly specialized professionals, with many of the administrative and paperwork responsibilities sometimes overwhelming them. Transcribing paperwork and documentation is one of those tasks. And among the documents being outsourced to a medical transcription company are referral letters.
Mastering the Art of Referral Letters
If there is one area of work where doctors might need a bit of assistance, since it isn’t exactly their core task, it would be in drafting referral letters. These letters only need to convey the point, but crafting them is certainly an art form that takes practice to master.
Effective patient care relies a lot on prompt information exchange between doctors, and referral letters are integral to this communication. It’s how doctors exchange vital information. It does save time when the sender crafts the letter appropriately with the actual needs of the recipient in mind without making it too long with unnecessary repetition. That ensures much time is saved for the recipient doctor or specialist, which can be spent on imparting care. It also prevents patient dissatisfaction, which eventually leads to a lack of confidence in the doctor.
Referral Letters Fall Short of their Potential
It has been discovered that the potential of referral letters is easily underexploited, which does affect the speed and the quality of care. In spite of the extent of clinician time spent on writing or dictating referrals, the quality, usefulness and conciseness of the information contained in them is often questionable. The Medical Journal of Australia (MJA) reveals that in studies conducted on referral letters, specialists have reported dissatisfaction with their content and quality, with concerns such as absence of:
- Adequate medical history
- Explanation for referral
- Test results
- Clinical findings, and
- Prior treatment details
Form letters have been used for enhancing the communication and information content of referrals from general practitioners to specialists and hospitals. These short form letters do contain a lot more relevant information, and an improvement in quality has been noted in referral letters as a result. However, MJA reveals that this has not led to an improvement in reply letters.
In Australia, general practitioners (GPs) have been found to prefer computer-generated, structured letters rather than dictated and unstructured ones. GPs also prefer computer-generated discharge documents. A structured letter contains a list of problems plus management proposals.
Basic Tips for Referrals
For doctors who must focus on patient care, here’s a brief guide that could help them craft better and more result-oriented referral letters:
- A simple referral may require just a few lines to describe the issue and basically express why the patient is being referred to the concerned specialist, and why the particular procedure or treatment is required. Details such as the social circumstances that are relevant to rehabilitation of the patient may also need to be included.
- Print-outs of medication, past medical history, previous diagnostic tests, etc would be required, if relevant to the condition dealt with. In long print-out reports, it is important to highlight important points to save time and keep up the concentration levels of the reader.
Referrals aren’t always this simple, though. There could be complicated referrals in which the initial diagnosis is unclear in the first place. Then it becomes difficult what to say. In such cases:
- It is important that you state right at the outset what you require from the specialist.
- Then you could go into the complicated medical history and examination.
- Again, when presenting the history, make sure to highlight the key points only rather than embarking on unnecessarily detailed description.
- It is also important to make the specialist aware of the importance of the problem being faced in functional terms.
Providing Crucial Details Succinctly
You also need to advise on the expectations of a patient of an appointment. Stress or anxiety in the patient regarding the health condition or the hospital visit must also be presented. These are factors that could help the specialist understand the patient’s problem better.
In the case of emergency referrals, it is better for them to be written or typed rather than dictated to a secretary. It is important to make them short and precise, and it is also essential to highlight important points regarding the patient’s medical and social history, since emergency referrals are usually read by the junior members of the hospital team.
Medical transcription outsourcing services also provide transcription of referral letters, which are part of the important documentation to be maintained by physicians. While a bit of effort and skill is required for crafting referrals, physicians at least need not be worried about getting them transcribed.