Creating Referral Letters for CUES/MECS
Introduction
This is a guidance page for creating referral letters for CUES and MECS on Opera.
Completing Clinical Notes
The 'Clinical signs, symptoms and observations' text box - highlighted below - should be populated with the following details:
- History and symptoms
- Clinical findings
- Treatment plan
- Advice given
- Follow-up arrangements
Referral Letter Information
Information to Note
- Referral letters and outcome reports are now streamlined into a single-page summary
- You do not need to attach a separate referral letter
- All information you want the hospital to see MUST be entered in the 'Details for referral letter box', highlighted in red outline in 'Creating a Referral Letter' below
- The 'Details for referral letter to hospital/GP' are the only clinical notes added to the referral letter generated
- Content entered in 'Clinical signs, symptoms and observations' is automatically duplicated into the referral section
- The duplication may not include all relevant detail or the appropriate structure as required for the referral - ensure this is review before submitting
- Information added to other free text boxes will NOT be visible.
- The only other information available to the practitioner will include:
- Referral for Action/For Information
- Patient Details
- Optical Practice details
- Assessment date
- Consultation outcome
- Preliminary diagnosis
- VAs
- Any medication recommendations
- Patient factors
When completing the 'Details for referral letter to hospital/GP' bow above, ensure the following are clearly documented in the referral box:
- Final diagnosis
- Clinical concerns/specific questions
- Advice given to the patient
- Required urgency (Same day/Urgent/Routine)
Creating a Referral Letter
1. When selecting referral to GP or HES as the assessment outcome, information included within 'Clinical signs, symptoms and observations' text box will be duplicated here:
2. The 'Details for referral letter to hospital/GP' must be updated with the relevant information required for the receiving practitioner to triage and determine next steps required, and urgency:
Information to Note
- The 'Details for referral letter to hospital/GP' are the only clinical notes added to the referral letter generated
- Information added to other free text boxes will NOT be visible.
- The only other information available to the practitioner will include:
- Referral for Action/For Information
- Referral urgency ( If the referral is noted as same-day, you must note down that you have given a copy to the patient)
- Patient Details
- Optical Practice details
- Assessment date
- Consultation outcome
- Preliminary diagnosis
- Visual Acuity
- Any medication recommendations
- Patient factors
Below is an example of an urgent referral generated from the information
Referring to the HES & GP
- If you need to do a referral to a GP as well as HES referral you will need to complete the ‘GP action’ section at the bottom of the page
- This will send the report to the GP with a notification of the HES referral AND an action for the GP (e.g. Cardiovascular check)
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Referring to the GP only
- If you select ‘refer to GP’ as the outcome, it will show ‘Referral for GP action’ at the top
Example Referral Letter
