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How to write a referral letter

geekymedics.com/how-to-write-a-referral-letter

April 28, 2018

What is a referral letter?


A referral letter is an essential means of communication between primary and secondary
care, giving the receiving clinician/department a detailed summary of the patient’s
presenting complaint and medical history to ensure a smooth transition of care. It is often
the only way information is passed from general practice, so it is important to ensure all
relevant details are included.

This guide gives a detailed description of each section that may be included in a typical
referral document. Each section lists the important pieces of information that should be
given to the receiving doctor and attempts to explain the rationale behind each part of the
document.

This guide aims to provide a general overview of writing a referral letter however in practice
each letter is tailored based on the clinical context, so not all information mentioned in this
guide needs to be included in every letter (as it may not be relevant).

You can download an example referral letter here and if you want a blank copy to practice
with you can download it here.

Patient demographics
It is vital this section is completed carefully and with the most up-to-date information, to
ensure the receiving department/physician can identify and make contact with the patient
without unnecessary delay.
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Essential pieces of information about the patient include:

Full name, title and the patient’s preferred name


Date of birth
Patient sex (sex at birth to help determine how the individual will be treated clinically)
Gender (how the patient identifies themselves)
Ethnicity
NHS number (or equivalent identifier)
Other identifiers (country specific or local identifier)
Full address and postcode
Contact telephone number (include mobile and home if available)
Patient email address
Communication preferences (if relevant) – preferred contact method (sign language,
letter, phone, etc) and preferred written communication format (e.g. large print,
braille).
Relevant contacts (e.g. next of kin, main informal carer, emergency contact)

Registered GP details
This section should be completed with the details of the General Practitioner with whom the
patient is registered. Note that this may be different from the physician the patient
presented to or the doctor who is referring the patient on for further care.

Fields to be completed in this section are the GP’s:

Name
Practice address and postcode
GP identifier (national code which identifies the practice)
Telephone and fax numbers
Email address

Referral details

Referral destination
This section should include the following details:

Name of receiving consultant and/or specialty clinic/department


Name and address of hospital
Hospital unit number

It is important that the patient is referred to the correct speciality, and two patients
with the same diagnosis may well require referrals to different specialities depending
on the details of their respective cases, for example:

Mr C presents with an 8mm basal cell carcinoma on the deltoid region of the left arm
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and is subsequently referred to dermatology for confirmation and excision.
Meanwhile, Mrs T presents with a similar basal cell carcinoma on the right side of her
nose, and due to the sensitive location of the lesion, her GP decides to refer to
plastic surgery who will consider the cosmetic outcomes of the required treatment.

Referring practitioner details


This section is to be completed if the patient is being referred by a practitioner/agency other
than their registered GP, as documented in the section above. This may be an out-of-hours
service, a different GP or a locum service for example.

If necessary, the following should be completed:

Name of referring practitioner/agency


Speciality
Address and postcode
Telephone, fax number, email

Special requirements
Transport (e.g. ambulance with oxygen)
Preferred language
Interpreter required
Advocate required

Presenting complaints
You should list the health problems and issues experienced by the patient that has resulted
in their attendance.

Examples include:

Symptoms (e.g. chest pain)


Medical conditions
Events such as trauma (e.g. fall)
Response (or lack of response) to treatment
Investigation results (e.g. abnormal LFTs)

History of each presenting complaint


The referring practitioner should carefully document the details surrounding each of the
patient’s presenting complaints to clearly convey the salient details to the receiving clinician
such that they can gain a clear picture of the clinical situation and are able to make a
reasonable and informed judgement on the case.

Information that should be documented includes, but is not limited to, the following:

Reported symptoms
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Onset
Duration
Severity
Relevant social, occupational and travel history

The exact details will vary depending on the case and to whom the referral is being made,
so each referral should be considered tailored to the case with additional relevant details
included.

Past medical history


Relevant summary of the patient’s significant medical, surgical and mental health
history
Active medical conditions and relevant resolved complaints
Previous relevant procedures and investigations
Relevant issues (e.g. anaesthesia problems/inability to tolerate MRI)
Past medical history plays an important role in subsequent care, so it is important the
receiving doctor has an accurate summation of this information.

Management to date
Accurately summarise the events that have occurred prior to referral:

Referral to other relevant specialities


Investigations
Current treatment (and previous treatment trials)
Patient’s management of their symptoms

Reason for referral


The referring doctor should be clear about why this patient is being referred to secondary
care (e.g. investigation, diagnosis, treatment) and what the expected outcome is. In some
cases, it may be reasonable to transfer full care of a patient to secondary care and in other
cases, the referral may be simply to gain a second opinion on the diagnosis followed by
management in primary care.

Possible examples include:

‘I would be grateful if Mr X could be referred to your care for full assessment,


investigation, management and follow up’
‘Mrs C is being referred for assessment and confirmation of diagnosis. Subsequent
management and follow up can be managed by myself in primary care’

Additionally, the type of care expected should be explicitly stated, for example, inpatient,
outpatient or emergency department care.

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Patient’s reason for referral
It is useful to document the patient’s and carer’s reason for referral as this may differ from
the clinician’s reason. You should include the patient’s or carer’s ideas, concerns and
expectations.

Urgency of referral
It should be made clear how quickly you expect this patient to be seen
(urgent/soon/routine).
If the referral is more urgent than routine, the reasoning for this should be
documented.
All patient’s with a suspected cancer should be directed to the suspected cancer
referral pathway to be evaluated within the recommended timeframe based on
specific protocols.

Examination
If an examination has been performed, the relevant findings should be noted.
Relevant vital signs should be documented (e.g. heart rate, blood pressure,
temperature, pulse, respiratory rate, level of consciousness).

Assessment scales
If relevant include calculated assessment scales such as:

Cognitive function (e.g. MMSE)


Activities of daily living
Mood assessment scale (e.g. geriatric depression score)
Developmental scales for children
Nutrition scales (e.g. MUST)
Pain scales (e.g. brief pain inventory)
New York heart failure scale

Relevant clinical risk factors


You should include relevant risk factors that are associated with the development of
a medical condition that is being considered in the differential diagnosis:

Smoking history for someone with suspected lung cancer


Sun exposure history for someone with suspected skin cancer
Industrial exposure for someone with suspected lung disease
Visual acuity for someone with falls

Specific risk assessment scores can also be included such as:


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Well’s score if considering pulmonary embolism

Investigations and results

Investigations requested
If investigations have been requested but the results are not yet available you should
document the type of investigations and the date they were requested

Investigation results
Document relevant investigation results

Family history
Document any relevant family illness that may be significant to the health or care of
the patient.

Social history
Living circumstances – who the patient lives with and the type of accommodation (e.g.
house, bungalow, hostel)

Relevant lifestyle information that may include:

Activity levels
Hobbies
Sexual habits
Recreational drugs
Smoking history
Alcohol intake
Driving status

Occupational history:

Include relevant occupational history (e.g. an individual working at height who has
suffered a blackout) or an ex-miner who has presented with respiratory symptoms.

Other social circumstances:

Relevant social concerns


Religious, ethnic and spiritual needs
Dependants

Social services:

Care packages (e.g. four times a day care, residential care, nursing care)
Social worker involvement
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Current and recent medication
A list of the patient’s currently prescribed medications and those recently
discontinued (including acute prescriptions) should be included.
Details of dose and frequency should also be noted.
If the referring practitioner has details of over the counter medications being taken by
the patient these should be documented.

Allergies
Document any allergies a patient has, including the type of reaction and when they
first experienced it.

Safety alerts
There are several important points that should be covered in this section if
applicable, including:

Risk to self (e.g. suicide, overdose, self-harm, self-neglect)


Risk to others (risks to care professionals or third parties)

Legal information

Consent for treatment


If a patient has been consented for investigation and/or treatment this should be
documented clearly.

Mental capacity assessment


If an assessment of mental capacity has been undertaken this should be documented
including:

Who carried out the assessment


When the assessment was carried out
Outcome of the assessment
If a best interests decision has been made because a patient lacks capacity this
should be documented clearly

Advanced decisions about treatment


If a patient has made advanced decisions about their treatment (e.g. if my heart stops I do
not want to be resuscitated) this should be documented, with the relevant documentation
(usually copies) included as part of the referral (e.g. signed forms by the patient).

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Lasting power of attorney
A lasting power of attorney is an individual who has been given the right to be involved in
healthcare decisions on behalf of the patient if they lack capacity.

The details of this person should be documented:

Name
Contact details
What role they have been assigned

Information given
Document any information have you given to the patient and make clear if there is
information they are currently unaware of (e.g. because the patient has asked not to
be told).
Document if you have given information to other third parties involved in the patient’s
care.
State if there are concerns about how well the patient/carer currently understands the
information provided regarding investigations, diagnosis, prognosis and treatment

Completing the referral letter


The end of the referral letter should include:

Referrers name
Referrers role
Date referral sent

Referrals in clinical practice


This guide is intended as a generic guide to the possible components of a referral letter. In
the real world of clinical practice, referral documents will vary greatly depending on the
country, health board and specialty being referred to. The guide has been kept purposefully
generic such that it can be adapted for use by anyone, anywhere and for a variety of
purposes.

References
1. Scottish Intercollegiate Guidelines Network (1998). Report on a Recommended Referral
Document [online]. Edinburgh. Available
at:http://www.sign.ac.uk/guidelines/fulltext/31/index.html [Accessed 6 Dec. 2017]

2. Academy of Royal Medical Colleges (July 2013). Standards for the clinical structure and
content of patient records. Document [online]. Available
at: https://www.rcplondon.ac.uk/projects/outputs/standards-clinical-structure-and-content-
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patient-records

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