A Referral Letter Criteria
HOW TO WRITE A REFERRAL LETTER
Referral letters are a vital, if time-consuming, aspect of a GP’s life. A well-written referral can make all the difference when a patient visits a specialist, and show a level of care and expertise on the part of the referring clinician.
Patient Details
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)
- 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
Presenting complaints
You should list the health problems and issues experienced by the patient that has resulted in their attendance.
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 judgment on the case.
Past medical history
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.