EyeTools Optometry Skills

309: Sending information to the patients doctor

I work in a community eye care practice and have just received a complaint letter from one of my patient’s general practitioner. I referred the patient because he had dot haemorrhages in the macula. The general practitioner has complained that he can’t understand the abbreviations I have used in my referral letter. Because he doesn’t understand my letter, he doesn’t know how to manage the patient. Do you have any tips as to how I can avoid receiving letters like this?

I have read many hundreds of referral letters from primary eye care practitioners to general practitioners, ophthalmologists, neurologists, and orthoptists in my role as an expert witness in medico-legal cases. Many of them contain abbreviations and shorthand. Some of these are standard abbreviations and are known in the primary eye care world and some are made up and used only in the practice from where the patient is being referred.

It is best not to use any abbreviations or shorthand of any form in a referral letter as this can lead to misunderstanding and harm coming to the patient. Even ophthalmologists won’t understand some of the primary eye care abbreviations as they are different from those used in ophthalmology. Use plain language and explain eye jargon when referring to a general practitioner. They have very little eye care training and do not understand primary eye care abbreviations or even simple eye care jargon. Everything in your referral letter to a general practitioner must be easy to understand. Assume you are writing to someone who has no eye care training or knowledge at all.

When referring a patient to an ophthalmologist, neurologist, or orthoptist it is okay to use jargon as they have the necessary training but don’t use primary eye care abbreviations.

Here is a recent example of a referral letter to a general practitioner sent by a primary eye care practitioner:

‘RE-2 haems seen with 1D/D of macular, superior, no distortion on Amsler.

LE-OH of wet AMD.

Can you refer?’

There was other information in the referral letter but the writing was so bad I couldn’t decipher it.

This would be much better as:

‘In the right eye, there are two haemorrhages in the centre of the retina. I don’t think this is due to age-related macular degeneration.

The patient has a history of wet age-related macular degeneration in the left eye.

Can you refer to an ophthalmologist specialising in retinal problems? Thank you.’

And remember to present the information so the receiving practitioner can read it.


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