일개 대학병원으로 의뢰된 환자의 진료 의뢰서 분석

Abstract

Purpose: In cases of a patient referral, the primary physician should communicate the patient’s medical information as clearly as possible to the doctor to whom he/she is referring his/her patient. For this reason, it is necessary to write a referral letter in an accurate and complete manner. Several studies on the referrals themselves have been published in Korea, but studies on the writing of medical referral letters are almost non-existent. This is the reason why we decided to investigate the current situation of consultation and referral among healthcare professionals by analyzing referral letters received by a Seoul-based university hospital. Methods: The analysis of the current practice of referral letter writing in Korea was performed by itemizing the contents of the referral letters received by a Seoul-based university hospital in a period of 1 month, from March 1 to March 31, 2011, and assessing their fidelity. Results: The analysis of the contents of the referral letters yielded the following results: communication of the referral, 98.6%; signature, 98.1%; records of major symptoms and diagnostic considerations, 60.1% and 82.3%, respectively; patient’s medical history, 27.3%; consultation-based opinions, 39.7%; investigation results, 26.3%; radiation test results, 23.5%; therapy information, 18.8%; concrete purpose for the referral, 45.5% (excluding self-referral, 7.8%); and request for a response, 0.44% (3 cases). Comparison between hospitals and private clinics showed that the level of fidelity 3 or higher (records of at least 6 out of 11 categories itemized) for the referral letters written in hospitals was higher (hospitals vs. clinics: 62.9% vs. 32.6%, p<0.001). The comparison of referral patients’ characteristics showed a higher fidelity in the emergency patients than in all the other patient groups (p<0.0001). Furthermore, the fidelity increased in proportion to the license number, i.e., in inverse proportion to the doctor’s age (p<0.001). Conclusion: The study confirmed the fact that the clinical practice of writing patient referral letters still leaves much to be desired. For a more adequate communication of information among healthcare professionals, it is important that doctors sharpen their own awareness, and it is necessary to create more clear and standardized guidelines for writing referral letters.