CSE Flashcards
What are the 7 points to remember for a transfer letter?
Referral details (to include admission date, ward, consultant and transfer date)
- Diagnosis
- Reason for transfer
- Progress
- Drugs on transfer
- Social History, O/E
- Investigations
- Follow up
- Info given to patient/family
SUMMARY
Referring doctor name
Your rank
Your contact details
Points for a referral letter?
Referral details standard
- Diagnosis
- Current problem
3.Key investigations
- Treatment to date
- Current medication
- Social history
Referring doctor name
Your rank
Your contact details
Points for a discharge letter?
Address of GP (and hosp and date)
Dear, Re:
Needs admission date, ward, consultant and discharge date
- Diagnosis
- Progress
- Key investigations
- Drugs on discharge
- Changes to meds/Changes to care
- Outstanding tests
- Follow up
- Info given to pt and family
What do you need to include on the diagnosis point?
- Referral letter
- Discharge summary
- Transfer letter
List of diagnoses
Referral letter
- Don’t necessarily need diagnosis but symptoms…
- ‘I would be grateful if you could review [pt name] regarding her [condition]…
Discharge letter & Transfer
- New diagnoses in order of importance
- Old ones afterwards
What do you need to include on the progress/details of admission point?
- Discharge summary
- Transfer letter
Try to synthesise everything that has happened.
Admitted on [date] as a [elective/emergency] with [symptoms]
Treatments and relevant investigations, and what they showed.
No need for specific doses or anything but try to summarise effectively.
State of the patient now
May include:
- Services seen
- Key PMH if relevant
For a referral letter, what do you need to include in the current problem point?
- Referral
Issue as they have presented
Relevant symptoms
How has disease changed, since first developed
What do you need to include on the key investigations point?
- Referral letter
- Discharge summary
- Transfer letter
Referral letter
- Only important ones, any pending
- Date performed
Transfer
- Clinically relevant
- Date performed
- Recently abnormal bloods
- Major scans like CT /MRI
- Any pending
Discharge
- Clinically relevant results including blood tests
- Date performed
- Any major investigations even if unremarkable
What do you need to include on the drugs on discharge/transfer point?
Generic name
Dose
Frequency
Route
Length of treatment
Allergies
Changes to medication point on the discharge letter?
What has been stopped, for how long and why
What has been initiated, their length and any actions to be taken
Any changes to their community care
What do you need to include in the follow up point on discharge letter?
Post-discharge plan:
- Clinic appointment? When, with whom?
- Any other services involved with follow-up
- What is expected of the GP, what the hospital is doing
- Any info the GP really needs to know e.g. DNACPR
- Good to include anything that will make life easier for the GP, e.g. get pt to book appointment, communicate well to the GP.
Info given to the patient
What do you need to include on the info given to pt or family point? (discharge)
Has pt/family been counselled about
- Current problem
- Reason for discharge
- Any further follow-up needed
In transfer finish with: ‘if you have any further questions please do not hesitate to contact me or….’
What do you need to include in the Social history point in a referral letter?
Smoking status, alcohol hx
Pt home and work situation
Disease affecting them?
Pt’s views on current situation
What has been explained so far
Anything important you have not told the pt
FInish with what you need from the consultant
- Diagnosis
- Management options
What do you need to include in the follow up point on transfer letter?
Transfer
- Clinic appointment? When, with whom?
- Any other services involved with follow-up
