In the case of a simple complaint such as a skin lesion, less information is required by the consultant than in the case of a more serious condition or a more complicated problem. The referral letter should reflect this.
- Introduce the patient
The letter should initially introduce the patient to the consultant. It should also detail the patient's age and their occupation if relevant (eg, farmer, nurse, hairdresser) and any other useful personal information.
- Give the clinical details
A detailed account of the current condition should be given, including site of the problem, its duration, severity and constancy and whether there are any associated symptoms.
In the case of pain, its radiation to other areas should also be mentioned. In the case of a psychiatric referral, inclusion of a short mental state assessment may be helpful.
Examination of the relevant area of the body should be fully detailed and, if appropriate, a more extensive examination of the patient should be noted. The results of any investigations undertaken should be outlined in the letter. In particular, any abnormal results obtained should be emphasised.
- Provide the patient's history
The patient's past medical history of relevance and any regular medication should be included in the letter.
When using computerised medical records, and in patients with complicated medical conditions, it may be appropriate to include a computer summary of the patient's full medical record.
However, some consultants may complain that there is no time in a busy clinic in which to read and take note of several pages of medical history.
- Explain what the patient expects
Any particular concerns the patient may have about his or her problem should be outlined, as well as any information you have already given the patient about the diagnosis.
The letter should close with an expression of thanks for the consultant's opinion.
- Patient's notes.
- Results of any investigations.
- Summary of medical records, if appropriate.
- Notes of any patient concerns.