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geekymedics.com/how-to-write-a-referral-letter
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:
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.
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:
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.
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:
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.
Management to date
Accurately summarise the events that have occurred prior to referral:
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:
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)
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.
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:
Legal information
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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.
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
Referrers name
Referrers role
Date referral sent
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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