As a health practitioner, you will probably treat a patient with 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 letter to the GP for referral is crucial to your job.
Developing the ability to write a referral letter requires some time and effort, but it’s worth it!
Good letters to GPs can actually improve your skills as a therapist. 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 important to include all 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.
Find out more about how practice management software will help you keep all your documentation safe here:
It is also a legal necessity as it serves as proof of negligence.
A follow-up with the patient once they’ve been referred is a good idea too: you can ensure they’ve received an appointment or been seen within the two-week referral period.
What should you include in your referral letters?
You should provide information about the patient’s condition; the required information 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:
1. Personal information
Introduce the patient to the consultant, including their age, occupation, and other important biographical 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)
- 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)
2. 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 differ from the physician the patient presented to or the doctor referring the patient for further care.
Fields to be completed in this section are the GPs:
- Practice address and postcode
- GP identifier (national code which identifies the practice)
- Telephone and fax numbers
- Email address
3. The Condition
Give a full description of the current condition, including its location, duration, intensity, consistency, and 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.
Performing a brief mental health assessment during a psychiatric referral may also be beneficial based on current guidelines and protocols such as NICE19.
Document each patient’s complaint meticulously so that the receiving physician understands the situation and can make an informed decision about the case.
Include the following information:
- Observed symptoms
- 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. The letter’s content will vary depending on the situation and the person being referred.
Outline any specific patient concerns and any previous information you’ve given them concerning the diagnosis. Also, include when you are seeing them again (if necessary).
Finally, thank the consultant for his or her input.
4. Medical History
If a patient has complicated medical concerns, a summary of the whole record might be appropriate.
If you keep your patient records securely in private practice software, it should be easy to export and include with your referral.
Include any relevant past medical information as well as any regular medications.
Information that should be documented includes, but is not limited to, the following:
- Active medical conditions and relevant resolved complaints
- Previous relevant procedures and investigations
- Relevant issues (e.g. anaesthesia problems/inability to tolerate MRI)
The referral letter must include all the necessary admin and clinical information for the consultant to prioritise the recommendation.
5. Current and Recent Medication
Include a list of the patient’s current medications and recently discontinued ones (including acute prescriptions).
It is also important to note the dose and frequency of the treatment.
The referring practitioner should document over-the-counter medications taken by the patient.
6. Referral Details
In this section, you should include the following information:
- Consultant name and/or speciality clinic/department name
- Hospital name and address
- Unit number in the hospital
Two patients with the same diagnosis may well need referrals to different specialities depending on the details of their respective cases, for instance:
- Clive is referred to dermatology for confirmation and excision of an 8mm basal cell carcinoma on the left arm’s deltoid region.
- Meanwhile, Rose has a similar basal cell carcinoma on the right side of her nose. She was referred to plastic surgery because of the sensitive location of the lesion. Plastic surgery will consider the cosmetic outcomes of the required treatment.
Referring Practitioner Details
The patient must complete this section if referred by a practitioner/agency other than their registered GP, as documented above. It may be an out-of-hours service, a different GP, or a locum service.
The following should be completed if necessary:
- Name of referring practitioner/agency
- Address and postcode
- Telephone, fax number, email
If the patient has any special requirements, document them:
- Transport (e.g. ambulance with oxygen)
- Preferred language
- Interpreter required
- Advocate required
7. Reason for referral
A referring physician should be clear about why the patient is referred to secondary care (e.g. investigation, diagnosis, treatment).
Transferring a patient’s full care to secondary care may be necessary. Some referrals are simply for a second opinion on the diagnosis, followed by primary care management.
- Please refer Clive to your care for a full assessment, investigation, management, and follow-up.
- I am referring Rose for an assessment and confirmation of her diagnosis. I can handle follow-up and subsequent management in primary care.
Moreover, the type of care expected should be explicitly stated, such as inpatient, outpatient, or emergency department treatment.
8. Urgency of Referral
Indicate how soon you expect this patient to be seen (urgent/soon/routine).
The reasoning should be documented if the referral is urgent rather than routine.
Patients with suspected cancer should be referred to the suspected cancer referral pathway to be evaluated within the recommended timeframe.
9. 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
Completing the referral letter
The end of the referral letter should include:
- Referrers name
- Referrers role
- Date referral sent
GP Referral Letter Template
Mrs Entwine, Gastroenterologist. 13 Abdominal Avenue, Edinburgh, EH54 6YB
Dear Dr. Jones,
[Information] RE: New Referral Ms Smith, DOB 01/01/1975 14 Acre Road, Edinburgh, EH12 8HY
[Situation] Thank you for seeing Ms Smith a 45-year-old female with difficulty in controlling gastro-oesophageal reflux disease, for your consideration of a gastroscopy.
[Background] She has had six months of worsening epigastric pain, worse after meals. She has not displayed any constitutional symptoms during this time. Her medical history includes obesity and a cholecystectomy in 2016. She is currently on 40mg of esomeprazole daily and has no allergies.
[Assessment] The only finding on physical examination is epigastric tenderness on palpation of her abdomen. Her most recent liver function tests (dated 01/03/2022) and upper abdominal ultrasound (dated 11/03/2022) were normal. A H. Pylori breath test (dated 11/03/2020) was negative. She has been managed with 40mg of esomeprazole daily for the past six months. She has also modified her diet and has been trying to lose weight.
[Request] Despite this, her symptoms persist. I would greatly appreciate your clinical review and consideration of a gastroscopy to confirm this diagnosis and ensure nil other pathology contributing to her symptoms.
Kind Regards, Dr Macdonald, Edinburgh Primary Practice, Edinburgh, EH12 5HF
When should you send referral feedback letters?
As a practising clinician, you’ll send referral letters and 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, 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 the confidence to make 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, remember 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 your therapy recommendations for the patient.
Finish with setting a date for your next contact, and notify the referee of the best way to reach you.
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.
Boost your efficiency, reduce your workload, and increase your profits with our tailored healthcare practice management software. Start your free trial today.
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, grab us for a quick chat.
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