11/13/24, 7\:42 PM Guide | Writing a referral letter

Writing a referral letter

Table of contents

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 is 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.
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 identi
Ethnicity
NHS number (or equivalent identi
Other identi
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 di
Fields to be completed in this section are the GP’s\:
Name
Practice address and postcode
GP identi
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Telephone and fax numbers
Email address

Referral details

Referral destination
This section should include the following details\:
Name of the receiving consultant and/or specialty clinic/department
Name and address of the 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 di
Mr C presents with an 8mm basal cell carcinoma on the deltoid region of the left arm and is subsequently referred to
dermatology for con
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 di
If necessary, the following should be completed\:
Name of referring practitioner/agency
Speciality
Address and postcode
Telephone, fax number, email
Special requirements
Document any special requirements the patient may have\:
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.
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Information that should be documented includes, but is not limited to, the following\:
Reported symptoms
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 tailored
to the case with additional relevant details included.

Past medical history

Provide a succinct summary of the patient's past medical history, highlighting conditions that are particularly relevant\:
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.
Examples include\:
‘ I w o u l d b e g r a t e f u l i f M r X c o u l d b e r e f e r r e d t o y o u r c a r e f o r f u l l a s s e s s m e n t , i n v e s t i ga t i o n , m a n a ge m e n t a n d f o l l o w u p .
’
‘ M r s C i s b e i n g r e f e r r e d f o r a s s e s s m e n t a n d c o n
m a n a g e d b y m y s e l f i n p r i m a r y c a r e .
’
Additionally, the type of care expected should be explicitly stated, for example, inpatient, outpatient or emergency department
care.
Patient's reason for referral
It is useful to document the patient's and carer's reason for referral as this may di
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 suspected cancer should be directed to the suspected cancer referral pathway to be evaluated within the
recommended timeframe based on speci
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Examination

If an examination has been performed, the relevant
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 di
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
Speci
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 signi
breast cancer).

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
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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 su
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

Current 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

Safety alerts

There are several important points that should be covered in this section if applicable, including\:
The risk to self (e.g. suicide, overdose, self-harm, self-neglect)
The 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
The 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
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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).
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 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\: [LINK].
2. Academy of Royal Medical Colleges (July 2013). Standards for the clinical structure and content of patient records. Document
[online]. Available at\: [LINK].
Source\: geekymedics.com
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