The accuracy of medical history information in referral letters
Dr Adrian DeAngelis
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.
Abbreviations and acronyms:
temporomandibular joint dysfunction
The maintenance of a detailed and accurate medical history is an essential element of patient care and considered by a number of dental regulatory bodies to form part of the minimum standard for dental records.1,2 The medical history serves as the first line of defence against medical complications during treatment3 and may be of direct significance to patient management. Thus, when initiating a referral to a specialist or other practitioner, it is extremely important that this information is passed on. Although every practitioner should take their own detailed medical history for each patient,1,2 the information provided in the referral letter acts as secondary check to ensure that no vital information is missed at the specialist consultation.3
Unlike the medical literature,4–6 to date there have been few studies in the dental literature that deal with the quality of or attempt to improve the information contained in referral letters to other practitioners.3,7–13 In those studies, a large number of referral letters were shown to have significant omissions7,12 and, on average, in only 40% of referral letters was the relevant medical history documented adequately.3,11
The use of a pro-forma has been shown to improve the quality of medical records.14 One study showed that only 17% of referral letters contained medical history information13 and although the use of a pro-forma did increase medical history reporting up to 81%,13 referring practitioners were more likely to omit other administrative details, such as their own address, when using such devices.11,12 However, in another study, the use of a pro-forma was not associated with an increase in quality of medical information.15
Only one study, conducted by one of the co-authors of this study, specifically examined the accuracy of the medical history details reported in referral letters and identified the medical information that was commonly omitted.3
The aim of this study follows the general parameters of the previous study3 to compare the medical information supplied within referral letters to that provided by patients, upon taking a new medical history, in order to identify common omissions and facilitate some comparisons.
The medical histories of new patients referred to the Royal Hobart Hospital Oral and Maxillofacial Unit were evaluated by a standard self-administered patient medical history questionnaire and interview by the examiner (AFD) as a part of the initial consultation appointment.
Where a positive medical history finding was identified, the details of the medical history were compared to those provided by the referring practitioner and recorded on a study pro-forma. The medical history findings were categorized into a number of distinct groupings. For each grouping, the examiner selected a single response.
Where the medical history findings were negative for a particular grouping, the response was classified as “No”. Where there was a positive medical history finding for a group that was adequately described in the referral, the response was classified as “Yes, in referral”. Likewise, a positive medical history finding that was not adequately described or explicitly mentioned was classified as “Yes, not in referral”. All data were then entered into an Excel spreadsheet (Microsoft Corp; Seattle, WA, USA).
A total of 54 new patients referred to the Oral and Maxillofacial Unit over a period of six months with positive medical histories were selected for inclusion into this study. Of these, 30 (55.6%) were referred for non-third molar tooth removal, 12 (22.2%) for assessment of pathology and 8 (14.8%) for third molar removal with other reasons accounting for the remaining 10% (Table 1).
Table 1. Reason for specialist referral
The majority of referrals were from general dentists within the public sector (44.4%) while medical general practitioners (33.3%) and medical specialists (16.7%) made up the remaining bulk of referring practitioners (Table 2).
Table 2. Practitioner type responsible for referral
Table 3 summarizes the overall findings and shows that on average, the completeness of medical information in the referral letter as compared to that identified in the consultation appointment was only 58.8%. An average of 1.31 relevant items were missing from the supplied medical history.
Table 3. Summary of medical history completeness for all referrals received
|No relevant findings missing||29.6% (16)||37.0% (10)||22.2% (6)|
|One relevant finding missed||33.3% (18)||25.9% (7)||40.7% (11)|
|Two relevant findings missing||18.5% (10)||14.8% (4)||22.2% (6)|
|Three relevant findings missing||13.0% (7)||18.5% (5)||7.4% (2)|
|Four relevant findings missing||5.6% (3)||3.7% (1)||7.4% (2)|
|Average relevant findings missing||1.31||1.26||1.37|
Medical information from dental practitioners was, on average, only 55.2% complete with approximately 1.26 relevant findings missing in the referral. Comparatively, the average completeness of information supplied by medical practitioners was somewhat higher at 62.4%. However, medical practitioner referrals had a slightly higher rate of omitting relevant findings (1.37), hinting that referrals from medical practitioners were likely to be more medically complex.
Overall however, only 29.6% of referral letters were 100% complete with higher rates of dental referrals (37%) than medical referrals (22.2%) being 100% complete.
Table 4 shows the completeness of findings in their various categories for all referral letters as a whole. The best reported items for all practitioners were bleeding tendencies, bisphosphonate use and diabetes. Osteoporosis, adverse drug reactions, cardiovascular disease and susceptibility to endocarditis was also reasonably well reported. By contrast, the worst reported items overall were infectious disease status, strokes, blackouts and epilepsy, as well as details of previous head and neck tumours/radiotherapy.
Table 4. Overall medical history completeness by findings for all referrals received
|Cardiovascular disease||42.6% (23)||34.8% (8)||65.2% (15)|
|Susceptibility to endocarditis*||14.8% (8)||37.5% (3)||62.5% (5)|
|Respiratory disease||35.2% (19)||47.4% (9)||52.6% (10)|
|Bleeding tendency||24.1% (13)||7.7% (1)||92.3% (12)|
|Immunosuppression/corticosteroids||14.8% (8)||37.5% (3)||62.5% (5)|
|HIV/HBV/HCV||13.0% (7)||71.4% (5)||28.6% (2)|
|Diabetes||14.8% (8)||25.0% (2)||75.0% (6)|
|Stroke/blackouts/epilepsy||22.2% (12)||66.7% (8)||33.3% (4)|
|Depression/psychiatric illness||22.2% (12)||50.0% (6)||50.0% (6)|
|Osteoporosis/bony oncology||27.8% (15)||40.0% (6)||60.0% (9)|
|Bisphosphonates||18.5% (10)||10.0% (1)||90.0% (9)|
|Head and neck tumours/radiotherapy||11.1% (6)||66.7% (4)||33.3% (2)|
|Adverse drug reactions/allergies||33.3% (18)||33.3% (6)||66.7% (12)|
|Other relevant||38.9% (21)||42.9% (9)||57.1% (12)|
Table 5 shows the differences in reporting rates between medical and dental practitioners. Dental practitioners were more likely to report allergies and drug reactions and slightly more likely to report cardiovascular diseases and bleeding tendencies but less likely to report immunosuppression states, corticosteroid usage, osteoporosis, previous malignancies, radiotherapy, as well as other general medical conditions.
Table 5. Medical history completeness by category for medical and dental referrals
|Cardiovascular disease||75.0% (9)||54.5% (6)|
|Susceptibility to endocarditis*||75.0% (3)||50.0% (2)|
|Respiratory disease||42.9% (3)||58.3% (7)|
|Bleeding tendency||100.0% (8)||80.0% (4)|
|Immunosuppression/corticosteroids||40.0% (2)||100.0% (3)|
|HIV/HBV/HCV||0.0% (0)||33.3% (2)|
|Diabetes||75.0% (3)||75.0% (3)|
|Stroke/blackouts/epilepsy||50.0% (3)||16.7% (1)|
|Depression/psychiatric illness||40.0% (2)||57.1% (4)|
|Osteoporosis/bony oncology||42.9% (3)||75.0% (6)|
|Bisphosphonates||83.3% (5)||100.0% (4)|
|Head and neck tumours/radiotherapy||0.0% (0)||66.7% (2)|
|Adverse drug reactions/allergies||87.5% (7)||50.0% (5)|
|Other relevant||25.0% (2)||76.9% (10)|
Compared to previous studies which quoted a range of 18–40% of referral letters containing an adequate medical history,3,11,13 this study has shown an overall completeness of 58.8% with referrals from medical practitioners on average being more complete than those from dental practitioners.
While this number is higher than in previous studies, no mention was made about exactly what criteria constituted a complete or adequate medical history. If it is assumed that only referrals that are not missing any relevant findings are considered to be “adequate”, then this number drops to 37% of dental referrals and 22.2% of medical referrals. This is comparable with the range reported previously.3,11,15
Although, the Australian Dental Association (ADA) provides a medical history pro-forma to its members, there is no evidence regarding the numbers of practitioners that utilize this service. Theoretically, a pro-forma provides a simple way of transferring medical information between practitioners. However, from the limited evidence available,13–15 it is uncertain whether or not this is the case.
Referrals from general medical practitioners were much more likely to be complete than those from medical specialists due to the almost ubiquitous use of computer software medical history and drug history records which could simply be printed out and sent with the referral letter. However, often the computer generated histories were not explicit in exactly which conditions were active currently or had been dealt with previously. Also, in a number of cases the patient’s medical problems could only be inferred from the medications listed in the referral with no specific mention of the condition anywhere in the referral itself. For the purposes of this study, these sorts of findings were considered to be lacking in enough detail to be considered “in the referral” as the practitioner was left to guess the real reason for the patient taking the medications in question.
The use of computerized dental records by general dental practitioners has been shown to improve the quality of dental records.16 One possibility would be to include a medical history section that will not allow the practitioner to proceed with further data entry until it had been completed or updated. In addition, when charging the ADA code for letter of referral, the software could automatically print a copy of the medical history for insertion into the letter by staff.
Compared to the study by Chambers and Scully in 1987,3 the overall rate of reporting relevant findings within the various categories was similar, with slight increases in the rates of reporting findings of infectious diseases, respiratory problems and a decrease in the rate of reporting diabetes, although the low numbers of diabetics in this study and the previous study make it difficult to make valid comparisons. As the 1987 study did not separate results between medical and dental referrals, no direct comparisons could be made.
Due to the recent controversy and publicity regarding bisphosphonate medications and the possibility of associated necrosis of the jaws following minor oral surgery,17,18 it is not surprising to find a high rate of reporting, nor the fact that bleeding tendencies were well reported given that a number of referrals for extractions were made to the unit to manage purported bleeding risk patients, such as those taking warfarin, antiplatelet agents or high-dose aspirin.20–22
The conceived stigma surrounding infectious disease risk patients and the concern of being considered discriminatory may possibly be the reason why it is poorly mentioned in the referrals. The lack of mention of previous head and neck cancer and radiation treatment was of great concern given that the referrals were for surgical treatments involving the jaws, such as extractions which posed a risk of osteoradionecrosis and may have required hyperbaric oxygen therapy before treatment.23
Perhaps the most worrying finding is the large number of referrals that were grossly incomplete, omitting three (13%) and four (5.6%) relevant findings from the medical history. Even more worrying were those referrals, a total of 12 out of 54, which supplied no medical history at all. It is uncertain whether the reason for these omissions is due to patient related factors, oversight on the referring practitioner’s part, or the result of inadequate records.
The results of this study show that the standard of medical information in referral letters has not noticeably improved in recent years and that in a large number of referrals, medical information may only be partially accurate or even non-existent. As such, the information contained in referral letters must be considered to be at best, incomplete.
The dental boards make it clear that it is the responsibility of the treating practitioner to collect and maintain an up-to-date medical history, thus highlighting the need for every practitioner to take, for their own records, a detailed medical history for every new and returning patient.