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1.13
Key points
x

Patient Referral
Peter Mossey

Referral of patients from primary care to secondary care is an indispensable part of clinical practice. Examination/diagnostic skills, underpinning knowledge, clinical judgement, self awareness and recognition of own limitations are implied underpinning skills. A competent letter of referral requires an ability to communicate effectively and appropriately by the written word.

Introduction
Among the aims of undergraduate dental education both the General Dental Council and the Quality Assurance Agency recognize that referral of patients to colleagues in the dental profession is an integral part of clinical practise. This is likely to become more commonplace with increasing emphasis on specialism, increased public awareness of what services and alternatives are available and increasingly specialized equipment and expertise are required. Referral is also a quality of care issue, and appropriate referral requires a range of professional, knowledge and attitudinal skills. Under The aim of undergraduate dental education the First Five Years (GDC 2002) states that: The undergraduate dental curriculum must allow students to acquire the clinical understanding in competence to practise without supervision, on graduation and at the same time to allow them to be aware of their limitations and need to refer for specialist advice. GDC (2002, paragraph 17) The dental graduate must be able to communicate effectively with patients, their families and associates and with other health professionals involved in their care. GDC (2002, paragraph 19)

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190 PATIENT REFERRAL

It is essential that graduating dentists understand the limitations of their current knowledge and clinical abilities. They should be aware of the range of treatments available, and of the current evidence to support their choices, but not be expected to be able to provide them all. In such circumstances they must be able to refer for an opinion on treatment and management by a suitably experienced/qualied individual. QAA (2002, paragraph 1.6 ) Furthermore among the transferable skills outlined, the same document states that the graduating dentist should have the ability to communicate effectively at all levels in both scientic and professional contexts using verbal, non-verbal and written means. QAA (2002, paragraph 3.1)

Intended learning outcomes

Exposure to integrated oral care units, outreach, outpatient medical and dental departments and ward-based referrals allows undergraduates to gain insight into a process and build on their knowledge until they become fully competent to make their own referrals.

The essential components of a competent referral

Letter from a general dental practitioner in primary care to a colleague in secondary care or in specialist practice should include the following: 1. Referrers details the information should include name of referring dentist:
x x x

Address (essential) Telephone number (desirable) Email address (optional)

2. Name of the person to whom you are referring the patient. This may be a specic person, or a department in secondary care without specifying the individual. 3. Patients details must include name, address, telephone number and date of birth. 4. Presenting complaint: it is important to record the patients own perception of the problem for which they are being referred. On occasion, views of a parent, guardian, older sibling or partner may be sought to obtain an accurate assessment of how the patient perceives the problem for which they are being referred. 5. Medical history: comment on whether there is any relevant medical history and whether or not the patient is on any drugs or medication. If so, this should be elaborated upon. Those aspects that are important for the general welfare of the patient or that may have an impact on the dental treatment should be specically mentioned. Women of reproductive age should be asked if they might be pregnant,

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THE ESSENTIAL COMPONENTS OF A COMPETENT REFERRAL

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Table 1.13.1 Intended learning outcomes for referral Be competent at Making and accepting referrals to and from colleagues Responding to a referral letter, fax, e-mail, telephone call, and grade the degree of urgency Write a referral letter to a colleague with demographic data, reason for referral, relevant background information including dental, medical and social information and medication Have knowledge of Systemic conditions that require appropriate referral for dental treatment at a special centre Reasons for referral to specialist, hospital dental practitioner Be familiar with Complex cases that require referral (assisting with recognition of personal limitations)

and if not whether they are using contraceptive measures. Other relatively common instances include allergies, diabetes, congenital heart problems or infective endocarditis (requiring antibiotic cover for invasive dental treatment), and whether consultation with the patients medical practitioner would be advisable. 6. Dental history: in all disciplines, oral hygiene status, caries experience, teeth of doubtful prognosis and any areas of hypoplasia or decalcication will be relevant. In the dental history it may also be relevant to record previous exposure to anaesthesia and radiography. The frequency of attendance and any concerns you may have about patient attitude, motivation or compliance based on your own experience of the patient in the past. 7. Social history: should record patients social habits that may impact on dental health such as smoking, alcohol consumption (particularly if it is felt that this may be excessive), other siblings and ability to attend. For example, orthodontic treatment requires regular attendance over a prolonged time period and the level of parental support and ability to attend should be recorded. It may also be useful to advise if the patient can attend at short notice. 8. Family history may also be included, particularly if the condition for whom the patient is being referred may have a familial or genetic contribution. Examples of common conditions that may have some genetic contribution are malocclusion, periodontal disease, hypodontia, rarer conditions with a genetic contribution such as cleft lip and/or palate or hereditary gingival bromatosis and even more rare

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single gene disorders such as dentinogenesis imperfecta, amelogenesis imperfecta, and cleidocranial dysostosis. 9. Reason for referral: provide appropriate detail on your examination, diagnosis, severity, differential diagnosis (if appropriate). Also describe the condition, perceived problem or aspect of treatment for which the patient is being referred. The oral soft tissues should also be examined and anything unusual reported and well known indices such as DMF, plaque and gingival indices might be noted. 10. Specify whether advice only is being sought or if the reason for referral is to have treatment carried out in secondary care. It is helpful to indicate what aspects of the treatment you might be willing to do, e.g. extractions or restorative treatment that is within the scope of your own skills. There may be positive advantages to doing so such as avoiding a treatment waiting list. 11. Enclosures: any previous records may be extremely helpful in the diagnosis and treatment planning related to the presenting complaint. It is also regarded as unethical clinical practice to repeat invasive procedures or records. The type of record will depend on the nature of the referral but radiographs, study models, photographs or, on occasion, previous appliances, dentures or components of treatment. The referral letter should be signed and if the signature is illegible or difcult to interpret, a stamp can be used or the name may be printed in bold underneath.

Checklist 23 Letter of Referral

Marking scheme Date of referral GDP details (name, address and phone number) Name, address and DOB of patient Reason for referral (advice and/or treatment requested) Key details of clinical problem Medical history and drugs Dental history Relevant social and family history Indication of urgency of referral Radiograph or other supporting documentation enclosed Signature and printed name of referring practitioner Letter reasonably clear and legible Yes No Not relevant

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REFERENCES AND FURTHER READING

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12. Abbreviations and jargon: while jargon and abbreviations should generally be avoided or explained, it is acceptable to use jargon or abbreviations that would reasonably be expected in the repertoire of the specialist to whom the referral is addressed. Hospital practitioners, specialist practitioners or those who limit their practise to particular aspects of dental care such as oral surgery, endodontics, orthodontics or implantology may receive referrals from colleagues in primary care. Upon receipt of such referrals they should respond to acknowledge receipt, and also to provide feedback on how their patient is to be managed, or to provide the advice or assistance requested. This reply will vary according to the nature of the referral received. For further information on specialty specic referrals, references such as White et al. (2004) concerning referral for oral cancer and Djemal et al. (2004) for restorative dentistry are useful. Details of these is beyond the scope of this chapter.

References and further reading

Djemal S., Chia M. and Ubaya-Narayange T. (2004) Quality improvement of referrals to a department of restorative dentistry following the use of a referral proforma by referring dental practitioners. British Dental Journal 197(2), 858. GDC (2002) The First Five Years: a framework for undergraduate dental education, 2nd edn. London, The General Dental Council. QAA (2002) Dentistry: academic standards. Subject benchmark statements. Gloucester, Quality Assurance Agency for Higher Education. White D. A., Morris A. J., Burgess L., Hamburger J. and Hamburger R. (2004) Facilitators and barriers to improving the quality of referrals for potential oral cancer. British Dental Journal 197(9), 53740.

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Name Name Address Telephone number Your details Patient details Address

Former name?

Date of birth Relevant medical history Telephone number

Advice only Treatment What you are prepared to do Your request

Referral Letters

Regular attender Previous dental history Oral hygiene Caries state

Radiographs Study models Photographs Patient Presenting complaint Parent, if child patient Your concern Enclosures