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). 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 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 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 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. 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: 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 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). 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/project...linical-structure-and-content-patient-records
