Referring a Patient

Introduction

‘Referring a patient’ is a common task for doctors, and you will likely have seen this as a medical student. It involves discussing a patient’s case with another specialty, usually for one of two reasons: 

• Your team feels that the patient’s care should be taken over by a particular specialty
• You would like the advice of another specialty for a patient under your care

The person you will refer to will depend on the specifics of the department, but usually you will refer to a registrar in a different specialty. Occasionally, you may need to refer to a consultant, they may ask that your registrar makes the referral to them.  

When would I need to refer a patient? 

Below are a few examples of when you would need to make a referral to another specialty.

Working in the emergency department

You have seen a patient in the emergency department who you suspect has appendicitis, so you refer to the on-call general surgery registrar who reviews your patient and admits them under general surgery. 

A patient comes to the emergency department with a headache and is found to have a subarachnoid haemorrhage. You refer them to neurosurgery at a tertiary hospital, as your hospital does not have a neurosurgery department. The neurosurgical team accepts your patient, and they are transferred by emergency ambulance to the tertiary centre.

Working on the wards

A patient with pneumonia on the respiratory ward is hyponatraemic. You would like the advice of the endocrinology team, so you refer to the on-call endocrinology registrar for a ward review. The endocrinology registrar reviews your patient on the ward and advises on managing the hyponatraemia. The patient remains admitted under the respiratory team. 

A patient is admitted to the geriatric ward with cellulitis, and you suspect that they may have dementia. Your registrar asks you to refer your patient to the memory clinic on discharge. You email the memory clinic coordinator to arrange this, and the patient is followed up in the community. 

Before you refer a patient 

Before you refer a patient to another specialty, make sure you are clear about why you are referring the patient.

As outlined above, there are different reasons for referring a patient, so make sure you have checked with your seniors what they want to gain from the referral. As a junior doctor, you will usually be asked by a senior colleague to make a referral on their behalf. 

As well as the reason for the referral, you should also read the patient notes to make sure that you are aware of their history, relevant investigation results and if they have been seen by that specialty before. 

If the patient has a known long-term problem relating to that specialty (e.g. they have been seen regularly by the gastroenterology department as an outpatient for ulcerative colitis), it is worth reading through any relevant letters in the patient’s notes. 

How to refer a patient 

There are different ways to refer a patient to a specialty, which varies between hospitals. Make sure to clarify how referrals work in your hospital with your colleagues team before making the referral.   

Telephone referrals

Telephone referrals can involve: 

1. Bleeping the specialty: this means finding the bleep number of the person you want to refer to, sending a ‘bleep’ via the telephone, and waiting for them to call you back
2. Calling an extension: the person you want to refer to may have their own extension number
3. Contacting switchboard: for a specialty at another hospital you may have to go through switchboard. If you are unsure of the contact details for someone in your hospital, you can always ask switchboard too.

Bleeping

When bleeping a specialty to make a referral, ensure you are bleeping the right person! This may sound obvious, but within a team there will be junior doctor and registrar bleeps. Advanced nurse practitioners or specialist nurses may also take referrals in that department. 

External referrals

If you have to call a specialty at another hospital, call the generic hospital number (which you can usually find via Google), which will take you through to switchboard.

Switchboard will then ask what specialty you would like to talk to. Sometimes you can be on hold for a very long time, and you may have to call up more than once before you are successful. 

Email referrals

Occasionally, a department will ask you to make your referral via email. This is common when referring a patient to an MDT meeting.

An example is if your patient has a scan for one problem and an incidental finding in another body system is found on that scan. You can email the MDT coordinator for another department, and that team will discuss the patient’s scans.  

Online portals

Some hospitals and departments use online systems to effectively ‘triage’ referrals. This may be the only way to contact that team urgently, as they may not hold bleeps or have a telephone number.

An example of this is referapatient.org. You are asked to enter your contact details, followed by the patient’s details and presentation through a series of questions. You then submit the referral to the department you are referring to, and the on-call doctor will review the notes. The doctor may contact you via your bleep or reply via the online system. 

Discussing the patient’s case

When referring a patient to a specialty, whether via telephone, email or online portal, you should use the SBAR communication tool to ensure that all necessary information is included.

This tool allows you to succinctly explain who you are, why you want that team’s advice, and what you would like from them.  

Situation

• Who: introduce yourself, clarify the name and grade of the person you are speaking to, and provide details of the patient you are talking about (name, sex, DOB, and hospital number)
• Where: patient’s location and your location
• When: timing of current problem
• What and why: make it clear what aspect of the patient’s care you need advice on and what you are referring for. You should also include working diagnosis, escalation of care, and resuscitation.

Background

• Provide an overview of the patient’s history of presenting complaint
• Also include information such as the reason for admission, drug history, allergies and relevant investigations

Assessment

• Communicate your clinical assessment of the patient, including their vital signs, examination findings (make sure to include relevant examination for the specialty you are referring to), and overall clinical impression

Recommendation

• Communicate what you believe the next step in management should be and ask what the specialty recommends
• If you have a specific request for the team you are referring to, then ask this now

Final steps

• It is important that the person you are referring to has understood what you have said and what you have asked them to do
• Clarify any questions they may have
• Clarify your expectation of their response (e.g. “So you’ll be coming within the next 5 minutes to review the patient?”).

Documenting the referral

As hospital teams change daily and many professionals look after the same patient, you must document your conversations when speaking to other specialties. Otherwise, your colleagues won’t know what has happened.

After you have referred a patient to a specialty, make sure to document the name of the person who you spoke to and their role (e.g. “discussed with Dr Evelyn Moore, on-call gastroenterology registrar”). Document what information you have discussed with them, the plan they have advised, and if they have accepted to take over the patient’s care if that was the purpose of the referral. 

If a specialty has accepted to take over a patient’s care, you will need to inform the nurse in charge or ward manager so that they can move the patient to the appropriate ward.

If the specialty who has accepted the patient is located in another hospital, you will need to make sure that the bed manager is informed. Usually, the nurse in charge will organise this. The bed manager can then liaise with the hospital to which the patient will be moving. In cases where a transfer is time critical (e.g. cauda equina being referred to neurosurgery), a ‘blue light’ transfer may be needed – emergency transfer via ambulance. 

If a specialty have advised a plan, make sure to action any jobs generated, or clarify if the specialty will be doing these themselves (e.g. requesting blood tests). Once investigations are back, your team can update the specialty with this new information.  

If a referral is rejected 

Sometimes a referral is rejected by a specialty, and it is important to ask the specialty why they are rejecting the referral. Once you have this information, you must escalate this to your senior, who can re-evaluate whether the referral is still necessary.  

If your senior still thinks the patient should be referred to that specialty, then it would be wise for your registrar or consultant to re-discuss themselves. Sometimes, specialties like to have to have a registrar-to-registrar or consultant-to-consultant referral.  

Hospitals usually have a policy where no referrals should be rejected, so it is rare for a specialty to reject a referral requested by a senior clinician. Make sure to document each conversation clearly in the patient notes.  

Top tips 

• Make it clear from the start of your conversation what it is that you would like the specialty to do
• Clear referrals with a concise SBAR make referring a patient easier for both the referrer and the person you are referring to
• Make sure to read the patient notes before referring so that you can provide the specialty easily with the information they need
• Make sure you have access to all relevant investigation results that they may need
• Document your conversations!