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The Editor

Medicine Clinics from the Tropics

New Delhi

Sir,

I was happy to note the comments on my editorial ‘Writing a good patient referral’, and agree with most of the points raised by the author to make it relevant for all referrals. The editorial was primarily written by me for improving residents writing referrals in hospital setting only in ours or similar hospital set ups as clarified by me in paragraph 2 of my editorial and noted by the author. I will like to comment on the author’s observations and suggestions:

“Primary care doctor” should be rephrased as “doctor or team primarily seeing or caring for the patient”: In a hospital setting the word ‘primary care doctor’ implies the same. However for making these pertinent for all referrals- interinstitutional or between primary and secondary/tertiary/quaternary levels – I agree with the authors that rephrasing it as “doctor or team primarily seeing or caring for the patient” is better.
Mention of ‘drug allergy’ in the referral note: point well taken. In our hospital as per the current practice for all in-hospital referrals, the referral sheet is a part of the file of the patient which goes to the referred doctor and any drug allergy is mentioned very clearly on top of the patient’s file. Any treatment prescribed by the referring doctor is not executed by the nursing staff unless vetted by the doctor primarily caring for the patient. However, I agree with the author that highlighting it once again in the referral note is a good idea especially for outpatient and interinstitutional referrals where the treatment written by the referred doctor is not vetted by the doctor primarily caring for the patient.
Consultant referral in case of emergency: I beg to differ with the author’s opinion that interdepartmental consultant referral should be signed by a resident only without involvement of his/her own consultant. It can lead to innumerable referrals to consultants at the whims and fancies of residents. If the resident primarily caring for the patient is not happy with the opinion of the resident of the referred department and the patient is critical- he/she can always call his/her own consultant who can call upon the consultant of the referred unit/department to discuss the case and take a call on whether his/her physical presence is required. The resident of the referred department may also call upon his consultant, if he/she is at a loss and feels the need. For non-critical cases consultant referrals should be signed by the treating consultant. This is also the practice being followed in our hospital presently.
‘Verbal or written consent of the patient regarding a specific referral’: Patients are always informed when they are being referred to another department regarding the necessity of a particular referral. If a patient does not objectthen verbal consent is taken as implied. As of now we are not takingany written consent for the same in our hospital, which is a public sector hospital providing free health care.

However, I agree that in institutions where a referral involves financial costs or when we are dealing with diseases with stigma, it will be a good idea to inform the patient/relative about the same and take signaturefor legal validity.

Electronic records and communications: I am happy to say that India is rapidly marching towards digitisation of all the hospital records. Many private hospitals especially in major cities have electronic records and communications now. Many are in the process of full digitisations including some government hospitals (including ours). Government dispensaries, smaller healthcare set ups do require some more time for it- though we all understand its advantages.

Thank you for raising all the valid points.

Dr Aparna Agrawal

Director Professor of Medicine

Lady Hardinge Medical College and Associated hospitals

New Delhi 110001 India

Reference:

Agrawal A. Writing a good patient referral. Medicine Clinics from the Tropics 2023;2(2). https://meditropics.com/?page_id=977&preview=true