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.
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 identifies themselves)
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:
Practice address and postcode
GP identifier (national code which identifies the practice)
Telephone and fax numbers
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 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
Address and postcode
Telephone, fax number, email
Transport (e.g. ambulance with oxygen)
You should list the health problems and issues experienced by the patient that has resulted in their attendance.
Symptoms (e.g. chest pain)
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:
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
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.
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.
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).
If relevant include calculated assessment scales such as:
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:
Well’s score if considering pulmonary embolism
Investigations and results
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
Document relevant investigation results
Document any relevant family illness that may be significant to the health or care of the patient.
Living circumstances – who the patient lives with and the type of accommodation (e.g. house, bungalow, hostel)
Relevant lifestyle information that may include:
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
Care packages (e.g. four times a day care, residential care, nursing care)
Social worker involvement
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.
Document any allergies a patient has, including the type of reaction and when they first experienced it.
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)
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).
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:
What role they have been assigned
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:
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.