Mariken Stegmann

Table 2. Desired content of referral letter and specialist letter Category  Referral letter  Specialist letter  Purpose  Reason for referral  Level of urgency  Purpose of the letter  Medical facts  Active diagnoses/history  Resuscitation policy  Medication allergies  Medication names  Medication doses and frequencies  Active diagnoses/history  Resuscitation policy  Medication allergies  Medication names  Medication doses and frequencies  Any clinical trial the patient is involved in*  History  Presenting symptoms  History of symptoms  Presenting symptoms   Psychosocial  information  Need for an interpreter  Diagnostic  pathway   Physical examination: Aberrant findings,  relevant for current problem  Investigations: Aberrant findings, relevant  for current problem  Physical examination: Aberrant findings, relevant for  current problem  Investigations: Aberrant findings, relevant for current  problem  Diagnosis  Provisional diagnosis/diagnosis  Whether tumour is localised of metastasised  Description of size and direct expansion of primary  tumour**  Description of expansion to regional lymph nodes  Description of distant metastasis  Treatment  Treatment options  Selected treatment (e.g. watchful waiting or surgery)  Explanations for chosen treatment  Aim of treatment: curative or palliative  Summary/conclusion of multidisciplinary consultation  Prognosis with treatment  Short‐term side‐effects of treatment*  Effective initiated treatment  Response on initiated treatment  Completion  Summary/conclusion  What the patient has been told  For what problems should the patient contact the  medical specialist?  Whom should the patient contact  Specific request to the GP  Hospitalisation  Discharge destination  Complications  Medication changes  Complete medication list  Active medical problems at discharge  Intentions regarding residual medical materials (e.g.,  drains or stitches)   * Less relevant in round 1. ** Less relevant in round 1 and also overall score < 70% in round 2 (62.7%), but  included because 71.4% for GPs in round 2.  7 87 Delphi consensus study of correspondence