Background and aims Communication is an essential component of high quality medical referrals. The aim was to evaluate the completion of intensive care referral forms and to develop a streamlined document to improve data capture as part of the referral process.
Methods The intensive care referral forms were audited over a three month period to assess degree of completion. A streamlined referral document was subsequently devised using the UK PICS ‘Example of essential referral information’. A re-audit was performed to assess for improvement in completion of referral data. Data was collected retrospectively and the new streamlined forms were reviewed as per the proforma set out in the initial audit of January–March 2013. The audit standard was that all sections of the referral form should contain information - 100% of details for each referral should be recorded.
Results Improvement was noted in a number of sections of the referral form. Completion of patient details improved by 57%. Capture of referral source details, circulatory status and disability status each improved by 7%. Recording of infection status improved by 8%. Recording of transport details improved by 79%. There was no improvement in recording airway status, breathing status or results of any initial investigations. Advice was recorded as being given prior to transfer in 93% of cases, an improvement of 9%.
Conclusions A concise referral document using UKPICS example has shown an improvement in various areas of data collection. Simplifying the form further may further improve data collection however risks overlooking essential information.