Referral documents - A key indicator of general practice quality

Objective To explore potential opportunity of developing and using standardised referral document between community health services and hospital care in China,for improving effectiveness and efficiency of referral service and ensuring quality of care and patient safety.Methods Literature review and document analysis.Results Referral letter is a tradition of western medicine and has changed it format referral form.Standardised general practice referral form has been found in Australia and its quality is assessed in practice accreditation.The standardised document contents contact details of general practitioner,specialist and patient;reason for patient referral;clinical information,including warnings,allergies,current medication,social history,past medical history,progress,and investigation results;as well as consent to referral and sharing relevant information.The benefits of standardised referral includes improving patient information flow,enabling improved triage,prioritization and management of patient,increasing efficiency of electronic referral process and improving use of computerized community health software applications.Standardised referral form has not been found.Traditional referral document is used and presented as San Lian Dan,triplicate form,which actually function as account keeping,instead of communicating between doctors.Conclusion China needs further studies on referral documents which practically and appropriately exchange patient information among medical service providers.Standardised referral document which supporting quality and continuous of patient care is especially required in context of healthcare development through strengthening community health services.