© 2000 Blackwell Science Ltd

ORIGINAL RESEARCH Ambulatory Child Health (2000) 6: 147–151

What do general practitioners and paediatricianswant from discharge letters?

Steve Turner and Ginny BirrellDepartment of Paediatrics, South Cleveland Hospital, Middlesbrough, UK

ABSTRACT

Objectives To ascertain the relative importance ascribed by general practitioners andhospital paediatricians to items of information given in paediatric finaldischarge letters, and determine general practitioner preference for theformat of such letters.

Design A questionnaire was sent to 158 local general practitioners and 24 hospital-based paediatricians.

Setting A district general hospital serving both a large industrialized urban area anda rural catchment area in Northern England.

Results One hundred and twenty-eight (81.0%) general practitioners and 23 (95.8%)hospital paediatricians responded. There was consensus on which items ofinformation were essential. These included correct diagnosis; correct drugdosage, frequency and duration; dates of admission; investigationsperformed; admission ward; case history, and admitting/responsibleconsultant. There were differences as to the essential nature of which doctorwrote the letter; why the child was admitted; parental information given.

Conclusions Many features of paediatric inpatient discharge letters are regarded with thesame priority by general practitioners and hospital paediatricians. However,there are some important differences in preferences between these groupsof doctors.

Keywords communication, discharge, letter, general practice, paediatrics

IntroductionFinal discharge letters are an essential part of bothhospital and general practice records. They provideimportant information for any future inpatient and out-patient care. It is imperative that discharge lettersmeet the needs of general practitioner, as well as thehospital practitioner.

There are financial implications for health serviceproviders, in that many purchaser contracts now

require letters to reach general practitioners within astated time. Furthermore, since these letters are themain interaction between primary and secondarycare, they act as a ‘shop window’ to the latter. Apromptly delivered, accurate and user-friendly letterreflects well on a department.

Previous studies have examined general practitionerpreferences for the structural aspects of letters fol-lowing discharge from general medical,1 psychiatry,2

orthopaedic3 and oncology4 units. These and otherstudies revealed that time lags are common and

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important details often omitted.1–6 Harding’s study ininner London found similar results and suggested thatall letters contain certain minimum details includingadmission and discharge dates, diagnosis, treatmentand follow-up arrangements, as well as more use ofthe telephone as a communication tool.7 Even so,researchers have not evaluated the preferences ofgeneral and hospital practitioners regarding thecontent of discharge letters.

In keeping with current trends towards evidence-based medicine, the goals of this study were to identify general practitioners’ and hospital paediatri-cians’ preferences for various kinds of informationwithin final discharge letters and the differences, ifany, between these groups. A second goal was to view the relative value placed on information in discharge letters and preferences for format. Therationale for conducting this study was prompted by one hospital’s effort to review and improve final discharge letters.

MethodThe study was centred on a large inner-city districtgeneral hospital serving inner-city and semirural com-munities. A standard questionnaire (Appendix 1) wasdevised by the two authors using questions from previous studies and taking advice from a generalpractitioner working in another area.

The questionnaire was sent complete with stamped,self-addressed envelope to 158 general practitionerswho work in the hospital catchment area. It was alsogiven to the 24 paediatricians working in the hospital.The paediatricians completed the questionnaireswithout knowing the preferences of either their hospital or community colleagues.

The first part of the study investigated preferences ofall doctors for discharge letter content. Respondentswere asked to score items of information as essentialor otherwise.

The second part of the study examined general practitioners’ preferences for discharge letter format.Doctors were asked to specify only one option foreach of these four questions.

No statistical methods were used to analyse theresults. The interpretation of the results is mostly sub-jective. The determination of statistical significancewould be a purely academic process that would notaid in the interpretation of the results. Such interpre-tation could be made using the results against thebackground of local geography, demography andcurrent satisfaction with the discharge letter system.A similar appraisal using this methodology couldprovide a specific local profile.

ResultsOverall, 83% of those surveyed responded: 128(81.1%) of the 158 general practitioners and 23(95.8%) of the 24 hospital paediatricians. Of the latter23, 6 were consultants, 7 registrars and 10 seniorhouse officers.

Table 1 compares responses between general practitioners and paediatricians, and Table 2 displaysgeneral practitioner preferences for discharge letterformat.

DiscussionThis is one of the first studies to view providers’ pref-erences for information in paediatric discharge lettersand to compare differences in preferences betweengeneral practitioners and hospital practitioners. Theresponse rate (83%) for the questionnaire was com-parable to or higher than other similar studies.2,3,5,8

This appears to reflect a high degree of interest bygeneral practitioners in discharge letters.

Some of the findings are straightforward andexpected. Most physicians, whether community orhospital-based, felt it essential to have correct detailsrelating to drug information, diagnosis and dates ofadmission. More interesting were differing prefer-ences for information between general practitionersand hospital paediatricians. The paediatricians pre-ferred direct access to results of investigations fromhospital records and were less interested in havingthis data included in the body of the final dischargeletter. Hospital-based paediatricians also felt parents

© 2000 Blackwell Science Ltd, Ambulatory Child Health 6(3), 147–151

ORIGINAL RESEARCH GPs, paediatricians and discharge letters 149

should receive a copy of the discharge letter in orderto better support continuity of care and to minimize the potential for conflicting advice. Although someresearchers have recommended separate final dis-charge letters for community physicians and hospitalists,3 given the greater commonalities in preferences rather than differences, it is our opinion

that hospital and general practitioners’ needs could bemet from the same letter.

General practitioners were equally divided in theirpreference for structured versus free-text letters. Thisfinding contrasts with other studies in that someresearchers found that most (92%) general practi-tioners preferred structured letters.5 Similarly, therewere equal preferences for a handwritten letter on theday of discharge or typed letters received within sevendays. Questionnaire wording may explain this, as par-ticipants were not offered a choice, but were insteadrequired to choose either structured or free-text, andhandwritten or typed letters.

Other helpful findings were that general practitionersconsider the speed with which they receive informa-tion of the essence, a finding consistent with previousresearch.6,7 Illegible handwritten letters were clearlyidentified as pointless. The use of abbreviations wasalso perceived as unhelpful and confusing. Finally, thebenefit of parent-held records was highlighted. Thefirst general practitioner to see a child soon after dis-charge rarely has information regarding the admis-sion. Posted letters can be sent to the wrong generalpractitioner. The child may be seen by the generalpractitioners’ partner, a locum, a member of the localdoctors’ cooperative, deputizing doctor or in an acci-dent and emergency department. Other studies havenoted the benefit of parent/patient-held records andfound these to be a more reliable mechanism for conveying information to general practitioners thanthe post.8

© 2000 Blackwell Science Ltd, Ambulatory Child Health 6(3), 147–151

Table 1: Percentages and absolute numbers of ‘essential’ responses

Items of information General practitioners Paediatric doctors

Correct drug dosage, frequency and duration 127/128 (99%) 21/23 (91%)Correct diagnosis 115/128 (89%) 23/23 (100%)Date admitted and discharged 82/128 (64%) 16/23 (70%)Date of follow-up 56/128 (44%) 6/20 (30%)What investigations were done 62/128 (48%) 10/23 (43%)What the results were 71/128 (55%) 7/23 (30%)What ward the child was on 8/128 (6%) 2/23 (9%)Which doctor wrote the letter 24/128 (19%) 11/22 (50%)Why the child was admitted 55/128 (43%) 16/23 (70%)What information was given to the parents 60/128 (47%) 17/23 (74%)What the history was 35/128 (27%) 7/23 (30%)Who the consultant was 87/128 (68%) 18/23 (78%)

Table 2: Responses of general practitioners regarding letterformat

1. Letter free text or structured?Prefer free text letter 45.7% (53/116)Prefer structured letter 44.8% (52/116)Volunteered ‘both’ 8.6% (10/116)Volunteered ‘either’ 0.9% (1/116)

2. Hand-written letter on dischargeor typed letter within seven days?Prefer handwritten letter on discharge 35.1% (40/114)Prefer typed letter within 7 days 39.5% (45/114)Volunteered ‘both’ 23.7% (27/114)Volunteered ‘either’ 1.8% (2/114)

3. In complex drug schedules, informed of all medications or only changes to medication?Prefer to know changes to 21.6% (25/116)

medication onlyPrefer to know all medications 77.6% (90/116)Volunteered ‘both’ 0.9% (1/116)

4. Prefer A4 (letter) or Lloyd George–sized letters?Prefer A4 (letter) size 66.4% (77/116)Prefer Lloyd George–size 31.0% (36/116)Volunteered ‘either’ 2.6% (3/116)

150 S Turner and G Birrell ORIGINAL RESEARCH

Implications for practiceAs a direct result of this study, we have altered our discharge letter policy and format. The letter ishandwritten onto carbonless copy paper of whichthere are three different coloured copies. The child isdischarged with the top copy. A second copy goes tofile for a typed copy to be made and forwarded to thegeneral practitioner in the post. A third copy is usedfor pharmacy details. There is no need for the hand-written letter to go to the general practitioner, andparents are advised to keep it with their parent-heldrecords. The letter has a very structured format givingspecific information about the admission, but also provides the opportunity for free text to allow for theunique nature of each admission to be detailed briefly.Our secretarial staff have found that this format ismuch quicker to dispatch to general practitioners com-pared to the previous system that we used, which waspredominantly free text. The need for two separatedischarge letters, i.e. an interim letter and a final letter,has therefore been abolished, reducing the workloadfor all staff concerned.

A well planned and structured discharge letter can bedesigned to meet the needs of both hospital pae-diatricians and general practitioners. Use of a ques-tionnaire to assess needs is helpful for determiningthe utility of current discharge letters and for iden-tifying objectives for changing its content and struc-ture. In addition, we found it critical to consider thetime needed to complete letters and the speed atwhich they can be delivered to community physicians.

This study was centred around one paediatric de-partment, thus the results only reflect local prefer-ence. A larger study in more than one region wouldbe useful to obtain a more general response, whichcould then be applicable elsewhere. In the future,guidelines for paediatric discharge letters could thenbe produced. With the advent of e-mail, much of the present time delay for discharge letters reachinggeneral practitioners could be abolished, although theletter would still need to be written, with an agreedformat, and a paper copy produced for hospital notes.The effectiveness and legality of such an approachwould be a useful area for future research.

Producing discharge letters involves a large amount ofmedical, secretarial and administrative time. This is

the first published evidence concerning the structureand information given in paediatric discharge letters.Following this study, we can be confident that the infor-mation in our future discharge letters is appropriate forboth general practitioners and hospital paediatricians.

Acknowledgements

We thank the general practitioners and paediatriciansof South Tees for their willing participation in thissurvey. Our thanks also go to Caroline Marshall,Jonathan Wyllie, John Matthews and Keith Birrell fortheir time.

References

1 Clements D (1992) An improved ‘interim dischargeletter’: a successful outcome from audit. Journal of the Royal College of Physicians of London, 26 (2): 169–171.

2 Craddock C and Craddock B (1989) Psychiatric dis-charge summaries: differing requirements of psychiatristsand general practitioners. British Medical Journal, 299:1382.

3 Macey A, Murphy J S G and Mollan R A B (1989) Howto dictate a discharge summary letter. British MedicalJournal, 298: 1646.

4 Bado W and Williams C J (1984) Usefulness of lettersfrom hospitals to general practitioners. British MedicalJournal, 288: 1813–1814.

5 Rawal J, Barnett P and Lloyd B W (1993) Use of struc-tured letters to improve communication between hospitaldoctors and general practitioners. British Medical Journal,307: 1044.

6 Mageean R J (1986) Study of ‘Discharge communica-tions’ from hospital. British Medical Journal, 293:1283–1284.

7 Harding J (1987) Study of discharge communicationsfrom hospital doctors to an inner London general practice.Journal of the Royal College of General Practice, 37:494–495.

8 Sandler D A and Mitchell J R A (1987) Interim dischargesummaries: How are they best delivered to general practi-tioners? British Medical Journal, 295: 1523–1525.

Correspondence: Dr G. Birrell, MBBS, MRCP, 2 Auton Court, Bearpark, Co. Durham, DH7 7AW, UKTel: +44 1910384 5755; e-mail: v.l.birrell@ncl.ac.uk

© 2000 Blackwell Science Ltd, Ambulatory Child Health 6(3), 147–151

ORIGINAL RESEARCH GPs, paediatricians and discharge letters 151

Appendix 1

Dear DrWe are currently reviewing our format for inpatient discharge letters to general practitioners and would value your thoughtson several points.

How would you describe the following (please circle the most appropriate answer):

1. Correct drug dosage, frequency and duration E U I N2. Correct diagnosis E U I N3. Date admitted and discharged E U I N4. Date of follow up (not only if planned) E U I N5. What investigations were done E U I N6. What the results were E U I N7. What ward the child was on E U I N8. Which doctor wrote the letter E U I N9. Why the child was admitted E U I N

10. What information was given to parents E U I N11. What the history was E U I N12. Who the consultant is E U I N

E = essentialU = usefulI = interestingN = not essential, interesting or useful

Please would you delete words so that the sentence reads how you would like it.

• I prefer letters that are free text/structured• I prefer a handwritten letter on discharge/a typed letter within seven days of discharge• In patients with complicated drug schedules (e.g. cystic fibrosis) I want to be informed in the discharge letter of changes

to medications only/all medications taken• I prefer letters to be A4/‘Lloyd-George’ size

© 2000 Blackwell Science Ltd, Ambulatory Child Health 6(3), 147–151