Introduction

Clinic letters to the general practitioner (GP) form an essential part of communication in a patient's care. One essential variable requiring 100% compliance is the laterality/side of the diagnosis. Rationale of this audit was to check compliance of the same in clinic letters, to implement changes within the department initially followed by trust wide change in policy to improve the same.

Material and Methods

Clinic letters over a period of time were read through in retrospect to see for mention of side. The exclusion criteria were COVID consenting letters over phone, “did not attend” letters and letters for spinal pathology.

After 1st limb of audit following actions were taken: doctor education, secretaries to remind the dictating doctor to mention side in the letter and putting up of laminated prompters in all T&O clinic rooms to remind doctors. Following this a 2nd limb was conducted with similar parameters.

Results

1st Limb:

Total letters 271: Fracture clinic- 126. Elective/orthopaedic clinic – 106. Excluded letters– 39.

2nd Limb:

Total letters 169: Fracture clinic- 91. Elective/orthopaedic clinic – 62. Excluded letters– 16.

Letters without the mention of side of diagnosis

1st Limb: Fracture clinic – 28 out of 126 (22.3%). Orthopaedic clinic – 12 out of 106 (11.3%).

2nd Limb: Fracture clinic – 2 out of 91 (2.2%). Orthopaedic clinic – 2 out of 62 (3.2%).

Conclusion

With the changes there was an overall compliance of 97.8% in fracture clinic and 96.8% compliance elective clinic dictations.