SEARCH

SEARCH BY CITATION

Keywords:

  • Medical history;
  • referral letters;
  • completeness;
  • accuracy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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:
GP

general practitioner

TMD

temporomandibular joint dysfunction

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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
Referral reasonNumber%
Wisdom teeth814.8%
Extractions3055.6%
TMD11.9%
Implants11.9%
Pathology1222.2%
Other23.7%

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
Referral sourceNumber%
Public dental2444.4%
Private dental23.7%
Specialist dental11.9%
Medical GP1833.3%
Medical specialist916.7%

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
CompletenessAll referralsDental referralsMedical referrals
No relevant findings missing29.6% (16)37.0% (10)22.2% (6)
One relevant finding missed33.3% (18)25.9% (7)40.7% (11)
Two relevant findings missing18.5% (10)14.8% (4)22.2% (6)
Three relevant findings missing13.0% (7)18.5% (5)7.4% (2)
Four relevant findings missing5.6% (3)3.7% (1)7.4% (2)
Average relevant findings missing1.311.261.37
Average Completeness58.8%55.2%62.4%

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
Medical history findingTotalNot in referralIn referral
  1. *Defined as a previous episode of endocarditis, heart valve replacement or valve disease in accordance with recent Therapeutic Guidelines.19

Cardiovascular disease42.6% (23)34.8% (8)65.2% (15)
Susceptibility to endocarditis*14.8% (8)37.5% (3)62.5% (5)
Respiratory disease35.2% (19)47.4% (9)52.6% (10)
Bleeding tendency24.1% (13)7.7% (1)92.3% (12)
Immunosuppression/corticosteroids14.8% (8)37.5% (3)62.5% (5)
HIV/HBV/HCV13.0% (7)71.4% (5)28.6% (2)
Diabetes14.8% (8)25.0% (2)75.0% (6)
Stroke/blackouts/epilepsy22.2% (12)66.7% (8)33.3% (4)
Depression/psychiatric illness22.2% (12)50.0% (6)50.0% (6)
Osteoporosis/bony oncology27.8% (15)40.0% (6)60.0% (9)
Bisphosphonates18.5% (10)10.0% (1)90.0% (9)
Head and neck tumours/radiotherapy11.1% (6)66.7% (4)33.3% (2)
Adverse drug reactions/allergies33.3% (18)33.3% (6)66.7% (12)
Other relevant38.9% (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
Medical history findingIn dental referralIn medical referral
  1. *Defined as a previous episode of endocarditis, heart valve replacement or valve disease in accordance with recent Therapeutic Guidelines.19

Cardiovascular disease75.0% (9)54.5% (6)
Susceptibility to endocarditis*75.0% (3)50.0% (2)
Respiratory disease42.9% (3)58.3% (7)
Bleeding tendency100.0% (8)80.0% (4)
Immunosuppression/corticosteroids40.0% (2)100.0% (3)
HIV/HBV/HCV0.0% (0)33.3% (2)
Diabetes75.0% (3)75.0% (3)
Stroke/blackouts/epilepsy50.0% (3)16.7% (1)
Depression/psychiatric illness40.0% (2)57.1% (4)
Osteoporosis/bony oncology42.9% (3)75.0% (6)
Bisphosphonates83.3% (5)100.0% (4)
Head and neck tumours/radiotherapy0.0% (0)66.7% (2)
Adverse drug reactions/allergies87.5% (7)50.0% (5)
Other relevant25.0% (2)76.9% (10)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

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.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  • 1
    Dental Practice Board of Victoria. Dental Records. Code of Practice No. C003. Issue date July 2007. URL: ‘http://www.dentprac.vic.gov.au/docs/c003.pdf’.
  • 2
    Dental Board of Tasmania. Dental Practitioners Registration Act 2001. Section 11(1). By-law No. 23/06/2006. Making and maintaining dental records. URL: ‘http://www.dentalboard.tas.gov.au/files/Dental%20Records%20FINAL%20-%208%20August%202006.pdf’.
  • 3
    Chambers I, Scully C. Medical information from referral letters. Oral Surg Oral Med Oral Pathol 1987;64:674676.
  • 4
    Park JC, Ross AH, Tole DM, Sparrow JM, Penny J, Mundasad MV. Evaluation of a new cataract surgery referral pathway. Eye (Lond) 2009;23:309313.
  • 5
    Kisloff B, Peele PB, Sharam R, Slivka A. Quality of patient referral information for open access endoscopic procedures. Gastrointest Endosc 2006;64:565569.
  • 6
    Campbell F, Parsons B, Ruth L. Analysis of referral letters to a department of old age psychiatry. Ir J Psych Med 2008;25:2428.
  • 7
    Navarro CM, Onofre MA, Sposto MR. Referral letters in oral medicine: an approach for the general dental practitioner. Int J Oral Maxillofac Surg 2001;30:448451.
  • 8
    Hammond M, Evans DR, Rock WP. A study of letters between general dental practitioners and consultant orthodontists. Br Dent J 1996;180:259263.
  • 9
    McAndrew R, Potts AJ, McAndrew M, Adam S. Opinions of dental consultants on the standard of referral letters in dentistry. Br Dent J 1997;182:2225. Erratum in Br Dent J 1997;182:133.
  • 10
    Snoad RJ, Eaton KA, Furniss JS, Newman HN. Appraisal of a standardised periodontal referral proforma. Br Dent J 1999;187:4246.
  • 11
    Thomas D, Royle I, John JH, Bainton P. Do referrals from primary dental care for treatment using general anaesthesia comply with General Dental Council guidelines? Prim Dent Care 2004;11:2630.
  • 12
    Baker RA, Anthony L, Sanders H. An audit of the quality of a referral document, designed in accordance with Scottish Intercollegiate Guidelines Network for paediatric exodontias under general anaesthesia. Int J Paediatr Dent 2006;16:307308.
  • 13
    Djemal S, Chia M, Ubaya-Narayange T. Quality improvement of referrals to a department of restorative dentistry following the use of a referral proforma by referring dental practitioners. Br Dent J 2004;197:8588.
  • 14
    Schmidt M, Rizvi N, Lee DM, Wood V, Amisano S, Fairley CK. An audit of completeness of clinical histories: before and after introduction of a pro-forma. Int J STD AIDS 2005;16:822824.
  • 15
    Kourkouta S, Darbar UR. An audit of the quality and content of periodontal referrals and the effect of implementing referral criteria. Prim Dent Care 2006;13:99106.
  • 16
    Richard S. “Bytes and bites”– using computerized clinical records to improve patient safety in general dental practice. Dent Update 2008;35:614616, 618-619.
  • 17
    Cheng A, Mavrokokki A, Carter G, et al. The dental implications of bisphosphonates and bone disease. Aust Dent J 2005;50(Supp 2):S4S13.
  • 18
    Sambrook P, Olver I, Goss AN. Bisphosphonates and osteonecrosis of the jaw. Aust Fam Physician 2006;35:801803.
  • 19
    Therapeutic Guidelines Limited. Infective Endocarditis Prophylaxis Expert Group. Prevention of endocarditis. 2008 update from Therapeutic guidelines: antibiotic version 13, and Therapeutic guidelines: oral and dental version 1. Melbourne: Therapeutic Guidelines Limited, 2008.
  • 20
    Brennan MT, Valerin MA, Noll JL, et al. Aspirin use and post-operative bleeding from dental extractions. J Dent Res 2008;87:740744.
  • 21
    Krishnan B, Shenoy NA, Alexander M. Exodontia and antiplatelet therapy. J Oral Maxillofac Surg 2008;66:20632066.
  • 22
    Brewer AK. Continuing warfarin therapy does not increase risk of bleeding for patients undergoing minor dental procedures. Evid Based Dent 2009;10:52.
  • 23
    Vudiniabola S, Pirone C, Williamson J, Goss AN. Hyperbaric oxygen in the therapeutic management of osteoradionecrosis of the facial bones. Int J Maxillofac Surg 2000;29:435438.