K.A. Oshikoya1, M.U. Orji2 and I.A. Oreagba2
- Dept. of Pharmacology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
- Dept. of Pharmacology, Therapeutics and Toxicology, College of Medicine University of Lagos, Nigeria.
Background: Medical literature has demonstrated that referral hospitals often receive inadequate information about the care and medications their patients received from referring hospitals.
Objectives: This study aimed to assess the completeness of referral letters, especially the medication history, for patient presenting at the children emergency room of a teaching hospital in Lagos, Nigeria.
Methods: A pro forma form was developed to obtain from the referral letters the demographic information of children referred to the emergency room of the Lagos University Teaching Hospital (LUTH), Idiaraba, over a period of three months. The nature of the referring centre, tentative diagnoses made at the referring centre, duration of illness prior to referral, vital signs and physical examination findings, investigation results, and treatment given were also extracted from the letters. In addition, we extracted from the letters the name, dosage, frequency and duration of use of medicines administered at the referring centres. Parents were also interviewed about the details of medicines used prior to presentation of their child at the referring centres.
Results: Among those referred with a letter, 100 patients met the inclusion criteria and constituted those evaluated in this study. Most of the patients were referred from general hospitals (31%), another tertiary hospital (29%), and private hospitals/clinics (24%). Gender (30%) and tentative diagnoses (12%) were omitted in the referral letters. However, information about the weight (82%), vital signs (57%), physical examination findings (44%), treatment given (92%), and medication history (71%) were much more omitted in the referral letters.
Conclusion: Medication history as well as many other data points is infrequently reported in referral letters to a tertiary care hospital in Lagos, Nigeria. Standard referral guidelines may be useful to improve documentation of medication history.
Keywords: Medication, History, Referral letters, Children, Emergency unit, Tertiary hospital
Dr. K.A. Oshikoya
Lagos State University College of
Ikeja, Lagos, Nigeria
Referral letters are the interface between healthcare professionals in the primary healthcare centre or general practice and centres for higher level of care.1 They are expected to provide information such as the demographics of the patient, the clinical information, and medication history. In addition, they are used by clinical staff and medical records for making appointments for a patient to see a doctor.
A medication history is a detailed, accurate and complete account of all prescribed and non-prescribed medications previously or currently taken by a patient prior to their referral to a higher level of care.2 Medication history gives useful insights into the allergic potentials of a patient, adherence to pharmacological and non-pharmacological treatments, social drug use and probable self-medication with complementary and alternative medicines.3,4 Provision of a detailed medication history; particularly in a referral letter, is critical to the success of diagnostic and patient management processes.5 This is because medication errors are strongly associated with inadequate or incomplete medication history.6, 7
Most referral letters are written mainly by physicians and, sometimes, by nurses. However, several studies conducted both in the developed and developing countries showed that a medication history is often documented inaccurately and incompletely in patients’ medical records.8 It lacks information regarding medication allergies, past prescription, non-prescription medications and patients’ adherence to prescribed doses.9, 10 Incorrect and inaccurate documentation of a medication history may result in inadequate or inappropriate use of medications.11
Medication history is mainly based on the patient’s self reported information provided at the time of hospital admission in a higher level of care. Often times, it is completely omitted in the referral letter as physicians are more concerned with the medical history of patients than any other relevant details. Inaccurate medication history is often caused by a patient’s unreliable memory, non-disclosure by the referring physician, hasty interviews, recording errors, or an interviewer’s
unfamiliarity with certain medicines.12 Therefore, it is imperative that the medication history documented in referral letters at the point of admission to another centre, especially tertiary hospital expected to provide further expert management, be evaluated for accuracy.
The literature suggests a lack of a gold standard that constitutes a “good referral letter” 13 and a “good medication history”.8 Formal definition of a good referral letter and a good medication history has not been included in most studies. Gleason et al 14 have expressed that healthcare professionals need to educate patients about the significance of providing detailed medication lists and updating the information at every hospital visit. A summary of safe-practice recommendations for reconciling medications at admission has been published in the Joint Commission Journal on Quality and Patient Safety.15 It is recommended that a complete and accurate list of current medications for each patient should be obtained upon admission. The objective is to develop the most complete medication list possible which may not always be feasible.
Medication history documented in referral letters may not have been evaluated in the developed countries because access to the electronic database of general practitioners by the physicians to whom a patient is referred is permissible in institutionalized hospitals. However, this may not be possible in developing countries where electronic data storage is scarcely available and inaccessible.
The World Health Organization (WHO) has recommended that a referral letter should contain the name and age of the patient, the date and time of referral, the description of the patient’s problems, the reason for referral (symptoms and signs leading to classification), the treatment that has been given, and any other information that the referral healthcare centre may need to know in order to care for the patient, such as earlier treatments of the illness or any immunizations given, in case of children.16 However, studies in developing countries evaluating the contents of referral letters and the information preferences of physicians receiving the letters are scantily reported in the literature. A study evaluating the content of paediatric referral letters to an emergency room in a University Teaching Hospital in South-Western Nigeria showed that over half of the 974 letters grossly lacked important information such as the patients’ age, the treatment given, the findings from the investigations performed, the medical history, and what the writers expect from the referral.17 The study did not include medication history as one of the contents evaluated. The authors recognised training and introduction of letter-format prompt forms as a means of improving the quality of correspondence between the referring physicians and paediatricians in Nigeria.
This study aimed at evaluating how much medication history is documented in the letters referring children from primary and secondary healthcare centres to the Lagos University Teaching Hospital (LUTH), Idi Araba, in Nigeria.