Tattersall M H, Griffin A, Dunn S M, Monaghan H, Scatchard K, Butow P N
Department of Cancer Medicine, University of Sydney, NSW.
Aust N Z J Med. 1995 Oct;25(5):479-82. doi: 10.1111/j.1445-5994.1995.tb01491.x.
There are no Australasian data on the preferred information content of letters from consultant physicians to referring doctors.
To survey referring general practitioners (GPs) and specialists concerning their preferences for letters from a consultant physician after a new patient consultation to include different categories of information. To investigate the information content of letters written by one medical oncologist to referring doctors after a new patient consultation and contrast with that of individualised letters written to patients.
Fifty-five referring GPs and 53 specialists were sent a questionnaire seeking their views on the information content of letters from consultant physicians. Ninety-four letters after a new patient consultation were selected at random and analysed for their information content, and compared with 182 individualised letters sent to patients.
Referring doctors wanted letters to contain details of diagnosis, clinical findings, test results and recommended future tests, treatment options, side effects and prognosis. Letters to referring doctors contained 19 items of information (range 8-33), while letters to patients contained a mean of 5.6 'salient' points (range 5-7). Both letters almost always stated the diagnosis, the presenting history and recommended treatment. Letters to patients more commonly presented information about prognosis, further tests, and explanation of symptoms than letters to doctors. In contrast, letters to referring doctors contained more information concerning the past medical, family, and drug history, clinical findings and test results.
Letters sent by a consultant oncologist are not well tailored to the information needs of the referring clinician. Summary letters sent to patients may be modified to include information required by referring doctors.
在澳大利亚，尚无关于会诊医师给转诊医生的信件中首选信息内容的数据。
调查转诊的全科医生（GP）和专科医生对于会诊医师在新患者会诊后信件中包含不同类别信息的偏好。调查一位肿瘤内科医生在新患者会诊后写给转诊医生的信件的信息内容，并与写给患者的个性化信件进行对比。
向55位转诊的全科医生和53位专科医生发送问卷，征求他们对会诊医师信件信息内容的看法。随机选取94封新患者会诊后的信件，分析其信息内容，并与182封发给患者的个性化信件进行比较。
转诊医生希望信件包含诊断细节、临床发现、检查结果以及推荐的后续检查、治疗方案、副作用和预后情况。写给转诊医生的信件包含19项信息（范围为8 - 33项），而写给患者的信件平均包含5.6个“关键”要点（范围为5 - 7个）。两类型信件几乎都总会提及诊断、现病史和推荐的治疗方法。与写给医生的信件相比，写给患者的信件更常呈现关于预后、进一步检查和症状解释的信息。相比之下，写给转诊医生的信件包含更多关于既往病史、家族史、用药史、临床发现和检查结果的信息。
肿瘤内科会诊医师发出的信件未能很好地满足转诊临床医生的信息需求。发给患者的总结性信件可进行修改，以纳入转诊医生所需的信息。
