Professional Conduct Competency 2.4

Competency 2.4: The ability to make a judgement regarding referral and an understanding of referral pathways

Referral of patients to another practitioner may be classed as an emergency, urgent or routine referral.  You need to know when to refer the patient to the GP, Hospital Eye Service or another eye care practitioner.

This competency examines your understanding of the professional protocols and guidelines together with your ability to recognise the limitations of your own professional competence and to safely refer on to a medical practitioner when appropriate.  It is important that you recognise the limitations of your own ability within optometry and to understand that in some cases, referral to a more experienced practitioner may be appropriate, e.g. paediatric orthoptic care.

The Assessor will expect to see evidence of this competency from a selection of Patient Records.  Ideally, your Logbook should contain a selection of cases that represent a spread of common ocular disease; cases that have required onward referral would be of great benefit to achieving this competency and you should note from the Quarterly Patient Episode Sheet for the second quarter, that there should be at least one case of referral for cataract surgery which could be used in this evidence.

It is also possible that the Assessor will ask Questions about those referrals that you have carried out, and you may be asked to justify why referral was not indicated for those records where ocular disease or abnormality was found but no referral carried out.  If your Logbook does not have a variety of cases to discuss, the Assessor may present some Case Scenarios for discussion instead.

When should you refer?

Referral is indicated where there are signs of ocular disease or abnormality that,

  • Have not been noted before
  • Have been noted but not investigated to your or the patient’s satisfaction
  • Have been noted or investigated but appear to have changed in appearance

Referral is also indicated in patients with symptoms that you have been unable to address.

For example: a 30 year old patient complaining of frontal headaches

Your eye examination reveals a small hypermetropic prescription.  Referral may not be indicated as it is likely that corrective spectacles will resolve the symptoms.  However, the patient should still be informed to consult his general medical practitioner should the headaches persist in spite of the correction.  If there appears to be no optometric explanation for the headache, then you should refer for medical opinion.

To whom should you refer?

If an ocular condition needs therapeutic care, or where the ocular condition is secondary to systemic disease, you should refer to the patient’s general medical practitioner.  In cases where the ocular manifestation of systemic disease is significant, referral for ophthalmological care may also be required.  When referring for an ophthalmologist’s opinion, it is appropriate in all but emergency cases to refer via the patient’s GP, indicating how soon you recommend that the patient be seen.

There may be some exceptions to this in your local area where fast track schemes exist for conditions such as glaucoma and cataract.  It is important that you know your local referral protocols.  When referring directly to hospital in an emergency, you should always send a copy of your referral letter to the GP.

How urgently should you refer?

This is best answered by asking yourself how quickly you want the patient to be seen.

If the ocular condition is immediately sight threatening, or the patient is in pain, then the referral should go directly to your local eye hospital or accident and emergency department.

Any condition that may potentially be a threat to life should be referred urgently via the GP, e.g. suspected pituitary tumour.

If the condition is of a chronic nature, a routine referral for ophthalmologist opinion is more appropriate.

If the ocular condition that you note is secondary to a systemic general condition, the urgency of the referral will depend upon the severity of the signs you detect and whether or not the patient’s condition is already being managed.  If the patient’s condition is already being managed, referral may not be required and it may be more appropriate to write a report to inform the GP.

It is not uncommon for a GP to call the practice to ask you how quickly you feel your patient should be seen if you are referring him to the local eye clinic. ‘Soon’ may not be adequate enough so within reason, try to indicate a time behind your referrals, for example, ‘Soon’ could be taken to mean either ‘within the week’ or ‘within the month.’

Referral letters

In most cases, referrals to the Hospital Eye Service (HES) should be made using the General Ophthalmic Services (GOS) 18 form.  In addition to filling out all the boxes, it should include the following information:

  • Presenting signs or symptoms as told by the patient
  • Ocular findings from the ophthalmic examination
  • Why referral is indicated (e.g. investigation for suspect glaucoma)
  • Urgency of referral: this may need to be justified if unusual
    • For example, an ‘urgent’ referral for cataract surgery if a patient that drives and who has bilateral cataracts that impair vision

Unacceptable Evidence

The following are examples of where the competency would not be met:

  • Failure to refer a patient that presents with signs or symptoms of a previously unrecorded ocular abnormality or disease
  • Failure to refer a patient where there is evidence of progression of a known ocular disease or abnormality
  • Inappropriate referral of a patient for emergency care
  • Failure to report ocular findings to patient’s GP where appropriate
  • Referral letters that contain insufficient information, or fail to indicate the urgency of referral, or recommend an inappropriate course of action
  • Poor knowledge of local referral pathways and protocols
  • Poor knowledge of the legal and professional responsibilities of an optometrist regarding the referral/notification to a patient’s GP

 

Additional study

Spend some time understanding the National Eyecare pathways.

 

 

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