What information should be included when typing up an order or referral for a vascular provider?

How to Correctly Type Up an Order/Referral for a Vascular Provider

A vascular referral must include: (1) documented communication recommending the referral, (2) an official referral order transmitted to the vascular provider, (3) complete patient cardiovascular history and risk factors, (4) relevant physical examination findings including pulse assessment and ABPI when available, (5) specific reason for referral with urgency level stated, and (6) all necessary patient enrollment information to allow the vascular provider to schedule and prepare for the consultation. 1, 2

Essential Components of the Referral Order

Patient Demographics and Contact Information

• Full name, date of birth, sex, and contact information 1
• Primary language and contact person 1
• Current living situation and level of independence 1
• Insurance information for authorization purposes 1

Cardiovascular History Documentation

Document all relevant cardiovascular history systematically: 1, 2, 3

• Previous vascular access or procedures: History of central venous catheters, pacemakers, previous arm/neck/chest surgery or trauma, and any prior vascular access attempts 1
• Cardiovascular disease: Myocardial infarction, angina, coronary artery bypass graft, percutaneous coronary intervention, arrhythmias/atrial fibrillation, congestive heart failure, peripheral artery disease 1, 2
• Cerebrovascular disease: Stroke (hemorrhagic or ischemic), transient ischemic attacks, carotid endarterectomy 1, 2
• Risk factors with specific documentation: Diabetes mellitus, hypertension, hyperlipidemia, smoking status (current/former/never with pack-years), obesity 1, 2, 4
• Anticoagulation status: Any coagulation disorders or anticoagulant therapy 1
• Comorbidities affecting prognosis: Malignancy, severe heart failure, renal disease, life expectancy considerations 1

Clinical Presentation and Symptoms

Specify the exact clinical scenario requiring vascular evaluation: 2, 4

• For claudication: Document claudication distance in meters/blocks, presence or absence of rest pain, and duration of symptoms 2
• For critical limb ischemia: Document presence of rest pain, tissue loss, ulceration, gangrene 2, 4
• Symptom progression: New onset versus chronic, stable versus worsening 2
• Functional impact: Ability to perform activities of daily living, exercise tolerance 1

Physical Examination Findings

Include specific vascular examination findings: 1, 2, 4

• Pulse examination: Character of peripheral pulses in all extremities, supplemented by hand-held Doppler evaluation when indicated 1
• Bilateral upper extremity blood pressures: Document both arms to assess for arterial insufficiency 1
• Lower extremity assessment: Presence of edema, arm size comparability, collateral veins, skin changes 1
• Critical ischemia signs: Skin temperature, color changes, capillary refill, presence of ulcers or gangrene 2
• Ankle-brachial pressure index (ABPI): If available, include ABPI values and Doppler waveform analysis results 4
• Allen test results: When upper extremity access is being considered 1

Diagnostic Test Results

Attach or reference all relevant diagnostic studies: 1, 4

• Arterial Doppler studies with segmental waveform analysis 4
• ABPI measurements (normal >0.9 and <1.3; abnormal <0.9 or >1.3) 4
• Venography or magnetic resonance imaging if central venous stenosis is suspected 1
• Arteriography results if performed 1
• Echocardiography results if heart failure is present 1

Current Medications

List all current medications with doses: 3

• Antiplatelet agents (aspirin, clopidogrel) 3
• ACE inhibitors or angiotensin receptor blockers 3
• Statins 3
• Antihypertensives 3
• Anticoagulants 1
• Diabetes medications 2

Urgency Level and Reason for Referral

Explicitly state the degree of urgency and specific reason for referral: 2

• Urgent (within 1-2 weeks): Critical limb ischemia, rapidly progressive symptoms, suspected acute vascular compromise 2
• Semi-urgent (within 4 weeks): Severe claudication limiting daily activities, rest pain, non-healing ulcers 2
• Routine (within 8-12 weeks): Stable claudication, vascular access planning for future dialysis 2
• Specific clinical question: State what you are asking the vascular specialist to address (e.g., "evaluate for revascularization candidacy," "assess for dialysis access placement," "evaluate abdominal aortic aneurysm") 5

Documentation of Communication with Patient

Document that you have discussed the referral with the patient: 1

• Documented communication between healthcare provider and patient recommending the vascular consultation 1
• Patient understanding and agreement with referral 1
• Document if patient refuses referral 1

Referral Transmission Requirements

Official Referral Order

The referral must include an official order transmitted to the vascular provider: 1

• Electronic or written communication between healthcare provider/system and vascular practice 1
• Include all necessary patient enrollment information 1
• Maintain HIPAA-compliant confidentiality 1
• Hospital discharge summary or office note may be formatted to include necessary information 1

Follow-up Coordination

Arrange specific follow-up: 1

• Schedule or request specific appointment timeframe based on urgency 2
• Provide patient with vascular provider contact information 1
• Document expected timeframe for vascular evaluation 2

Common Pitfalls to Avoid

Inadequate documentation is the primary reason for inappropriate referrals and delays in care: 2, 4

• Failing to state urgency: 66% of referral letters fail to mention degree of urgency, resulting in only 3% of patients being seen within 4 weeks versus 22% when urgency is stated 2
• Omitting claudication distance: Only 37% of referrals for lower limb ischemia mention claudication distance 2
• Poor documentation of risk factors: Diabetes mentioned in only 19%, hypertension in 43%, smoking in 31% of referrals 2
• Missing critical ischemia signs: 90% of referrals fail to document presence or absence of critical ischemic signs 2
• Inappropriate referrals: 41% of patients referred for suspected peripheral arterial disease have normal ABPI and do not require vascular surgery consultation 4
• Incomplete cardiovascular history: Failing to document previous central venous catheters, pacemakers, or prior vascular procedures that may affect treatment options 1

Consider obtaining ABPI measurement in primary care before referral to improve triage accuracy and resource utilization. 4