As a health practitioner, you will probably treat a patient who has a problem that is beyond your scope of practice or expertise, and demands a second opinion from a specialist. 

You may need to refer a patient to their GP, or send them for an x-ray or a scan, so writing a GP letter for referral is a crucial aspect of your job. 

Developing the ability to write a referral letter requires some time and effort, but it’s worth it! 

Good GP referral letters can actually improve your skills as a therapist. 

How?

Well, referral letters can affect a GP’s ability to prioritise your patient accurately, based on the letter’s content and presentation.

This article takes a look at what makes a really successful referral letter.

What is a referral letter?

A referral letter is a vital form of communication between primary and secondary care, and can play an important role in the early pathway of patient care. A poorly written referral letter could cause the patient’s treatment to be delayed, which can result in a worse prognosis. 

To ensure a seamless transition of care, the patient’s initial complaint and medical history need to be provided to the new therapist or clinician.

It is often the only means of passing on knowledge, so it’s really important to include all the relevant facts.

Referral letters are crucial for good record-keeping, too. 

A copy of the referral letter, the date it was emailed or posted, and copies of any responses should all be saved in the patient’s record in your practice management system.

It is also a legal necessity as it serves as proof against negligence. 

A follow-up with the patient once they’ve been referred is a good idea too: you can make sure they’ve received an appointment or been seen within the two-week referral period.

Does the patient require a referral?

A survey of GPs found that each doctor is already receiving an average of 6.2 inappropriate referrals every month, so it’s really important to make sure that your referral is necessary.

Usually, a referral will be determined by your level of confidence in the diagnosis and treatment of an illness. 

Other factors that can affect the outcome include the relative experience of other doctors and the availability of local services.

Try to gain a good understanding of local practices and services so that you can make an appropriate referral. In some regions, a patient with fibromyalgia would be referred to a rheumatologist, while in others, a chronic pain program might be able to help. 

Minor surgery may be referred to specialists by some doctors, while others perform the procedures themselves.

Understanding who has expertise in each area of the practice is critical.

If the patient needs ongoing care, such as for a chronic health condition, you can provide a referral that lasts longer or is indefinite. 

If the patient develops a new condition, you’ll need to give a new referral for it.

Once you’ve determined that a referral is required, you can then set out what you want to accomplish from it. This will help you decide where and to whom to refer the patient to. 

What should you include in your referral letters?

You should provide information about the patient’s condition; the amount of information required depends on the specific complaint. 

Setting up a letter or document template in your clinic management software will help you to remember exactly what to include, and will keep your referral letters consistent and professional.

An ideal referral letter should include the following:

  • Personal information

Introduce the patient to the consultant, including their age, occupation, and any other important biographical details.

  • The condition

Give a full description of the current condition, including its location, duration, intensity, consistency, and any accompanying symptoms. 

For instance, if there is a history of trauma, document whether it is a new pain or a recurring issue, and if the client is systemically well.

It may also be beneficial to perform a brief mental health assessment in the event of psychiatric referral, based on current guidelines and protocols such as NICE19. 

Document each patient’s complaint meticulously, so that the receiving physician has a comprehensive understanding of the situation and can make an informed decision about the case.

Include the following information:

  • Observed symptoms
  • Severity
  • Relevant occupational, family and travel history 
  • Any mobility issues – do they need transport arranged to attend appointments?
  • Relevant risk factors
  • Allergy information
  • Legal information such as consent

Every GP referral letter should be adapted to the case, and include any additional relevant information. Depending on the situation and the person being referred, the content of the letter will vary.

Outline any specific concerns the patient has, as well as any previous information you’ve given them concerning the diagnosis. Also include when you’ll be seeing them again (if necessary). 

Finally, thank the consultant for his or her input.

  • Medical records

If a patient has complicated medical concerns, a summary of the whole record might be appropriate.

If you keep your patient records securely in a private practice software, it should be very easy for you to export this and include it with your referral. 

Include any relevant past medical information as well as any regular medications. 

For the consultant to prioritise the recommendation, all the necessary admin and clinical information must be included in the referral letter.

As a referrer, what are you looking for?

Whenever an urgent issue arises, you should send a referral letter to the appropriate GP surgery email address, followed by a phone call to the GP to find out if the issue can be escalated quickly.

Be aware of time of week:

You might have to find a way to help them sooner if it is a Friday afternoon, or if it is before a long weekend, and your patient can’t wait.

Give patients emergency advice if they have an infection or severe symptoms, referring them to local NHS24, urgent care clinics, or A&E clinics.

After you’ve sent a referral letter, you’ll be looking to receive confirmation that your referral was successful and that another health expert is now helping in managing your patient’s condition.

You’ll also want to get the expertise or advice of a fellow professional to boost your skills. 

When should you send referral feedback letters?

As a practising clinician, you’ll not only send referral letters but also receive them, so you need to acknowledge any referrals sent to you. 

Some of the best times to send referral feedback letters include:

  • Immediately after receiving the referral

Generally, if you are able to attend to the patient soon after the referral, you can usually wait until after you’ve had your initial consultation with the patient. 

If you are not attending to the referral immediately though, a simple response acknowledging the referral is the best thing to do.

  • After your initial assessment

Following your initial assessment of the patient, send the referrer a letter informing them that you’ve completed the first consultation, your clinical perceptions, the treatment goals established, your planned interventions, and when they can expect the next status report from you. 

Even if your evaluation takes more than one session, it’s worth writing a note to the referrer informing them of the first appointment and any early clinical opinions you have.

  • During the course of treatment

Midway through treatment, giving an update keeps the referrer informed, reassures them that the patient is getting treatment, and gives them confidence in making their own treatment decisions. 

  • During the end of treatment

Informing your referrer that the treatment has ended is crucial as it informs them whether the intervention was successful or unsuccessful due to patient relocation, disengagement or other reasons.

How to write a great referral feedback letter

A good feedback letter should be able to tell a story about the treatment. 

Paragraphs should have a purpose and advance the narrative coherently.

The referrer’s name and address and the client’s name and identifiers should be at the top of the page.

Briefly summarise the letter’s history, referral, and the context in the introduction. While this may seem insignificant, keep in mind that some clinicians make several referrals per month and receive a steady stream of feedback. A note of why the patient was referred to you could help them quickly contextualise your feedback.

Provide an overview of the patient’s most recent treatment focus and applied interventions. 

Give an overview of the patient’s engagement with and response to therapy, such as how their condition has changed. At this point, you can ask the referrer for approval if more sessions are needed.

If applicable, include brief comments regarding any therapy recommendations you have for the patient. 

Finish with setting a date for your next contact, and notify the referee of the best way to reach you.

Conclusion

Specialists depend on referral letters to determine which cases to prioritise and book in their clinics.

Patients who are referred with brief or incomplete referral letters may not be booked for ‘urgent’ access which can end up delaying their treatments.

Referral letters can be particularly demanding when trying to run your private practice, but they don’t need to be.  

To make the whole process easier for you, using a practice management system like WriteUpp means you can set up referral letter templates for every eventuality. Your letters will be consistent, professional, and saved directly to the patient’s record.

What’s more: you can even send them straight to the client’s GP from within your system, meaning all your correspondence can be saved securely online too. 

If you’d like to know more about how WriteUpp can help you to write better referral letters, and streamline the overall management of your practice, just grab us for a quick chat.

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