Universidade Estadual de Campinas - Unicamp, Piracicaba Dental School, Department of Oral Diagnosis, Piracicaba, SP, Brazil.
Braz Oral Res. 2021 Apr 26;35:e037. doi: 10.1590/1807-3107bor-2021.vol35.0037. eCollection 2021.
Optimizing the quality of referral letters could be the first step to a correct clinical approach for patients. Referral letters should be legible and contain the necessary information to avoid delaying the patient's diagnosis and treatment. However, to date, few studies have been conducted on how referrals are performed in Brazil. Knowledge regarding the quality of referral letters can provide information to better guide health care professionals. This study was aimed at analyzing all referrals received by a single oral medicine service in Brazil. Referral letters were classified into poor, regular, good, and excellent based on key items concerning the primary morphology of the lesion, location, diagnostic hypothesis, symptomatology, time of evolution, consistency, size, and limits. A total of 500 referral letters were evaluated, including 271 (54.2%) from a private service and 229 (45.8%) from a public service. Dentists and physicians had written 475 (95%) and 25 (5%) referral letters, respectively. Among the 500 referrals analyzed in this study, the number of regular, poor, good, and excellent referrals was 236 (47.2%), 203 (40.6%), 58 (11.6%), and one (0.6%), respectively, showing a lack of important clinical information in referrals.
优化转诊信的质量可能是为患者提供正确临床治疗的第一步。转诊信应清晰易读,并包含必要的信息,以避免延误患者的诊断和治疗。然而,迄今为止,关于巴西转诊情况的研究甚少。对转诊信质量的了解可以提供信息,以更好地指导医疗保健专业人员。本研究旨在分析巴西一家口腔医学单一服务机构收到的所有转诊信。根据病变的主要形态、位置、诊断假设、症状、演变时间、一致性、大小和界限等关键项目,将转诊信分为差、一般、好和优。共评估了 500 封转诊信,其中 271 封(54.2%)来自私立服务机构,229 封(45.8%)来自公立服务机构。牙医和内科医生分别写了 475 封(95%)和 25 封(5%)转诊信。在本研究分析的 500 封转诊信中,一般、差、好和优的转诊信数量分别为 236 封(47.2%)、203 封(40.6%)、58 封(11.6%)和 1 封(0.6%),表明转诊信中缺乏重要的临床信息。