Assessment Of Completeness Of Documentation Of Referral Papers And Reasons For Referral Among Referred Patients To Tash Ed.

INTRODUCTION: In the referral process, referral papers are the standard and typically the solernmethod of communicating information between general practitioners and hospital specialists.rnSub-optimal referral letter can be a source of poor continuity of care (delayed diagnosis, multiplernmedication, multi-drug resistance, high litigation risk, unnecessary testing and extra-medicalrncosts) and therefore, decrease the quality of care. Referral papers of high quality are an essentialrnpart of good clinical care and act as the interface between health care professionals in primary,rnsecondary and tertiary care.rnOBJECTIVE: The aim of this study is to assess the quality of documentation on referral papersrnof patients referred to Tikur Anbessa Specialized Hospital Emergency adult, pediatrics andrngynecology and obstetrics departments.rnMETHODOLOGY: This study was conducted at TASH EDs from December- June 2014 byrnimplementing a retrospective cross sectional study design. A total of 1011 patient referral papersrnwere recruited by simple random sampling method. Data was collected from patients’ individualrnfolders retrospectively. For collecting relevant information, data was collected by using dummyrntables and analyzed using SPSS version 20.0.rnRESULTS: All 1011 eligible referral letters from Tikur Anbessa Specialized HospitalrnEmergency Department were systematically assessed in this study. The result shows that thernname of the patient featured in all of referral letter (100%, n=1011). Only 29.8% of referralrnletters bearing the patient’s address while 70.3% of referral letters contain history of presentrnillness; 30.3% of referral letter contain physical examination and 19.4% of referral lettersrncontain all the vital signs. The histories of allergies were reflected in none of the referralrnletters. About 12.2% referral letters were not entirely legible.rnCONCLUSION: Most of the socio-demographic data except the address were documented inrnthe referral papers. The clinical information section (the most important part) of the referralrnpaper was strikingly deficient especially history of allergy, vital signs, physical examinationrnfindings, chief complaint(s), results of basic investigations, treatment given. Only the workingrndiagnosis and reason for referral were documented in most referral papers. In a quarter of referralrnpapers assessed, the receiving unit was not mentioned, of which more than half wrote to anyrnhospital. Signature of the referring clinician rather than name or qualification was documented

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