A registrar survival guide ... writing a referral letter

The amount of information required in a letter of referral depends on the problem being referred.

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.

Essentials checklist

  • Patient's notes.
  • Results of any investigations.
  • Summary of medical records, if appropriate.
  • Notes of any patient concerns.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

UK COVID-19 vaccination programme tracker

UK COVID-19 vaccination programme tracker

GPs across the UK are playing a leading role in the largest-ever NHS vaccination...

BMA suspends GP committee election to investigate potential rule breach

BMA suspends GP committee election to investigate potential rule breach

The BMA has suspended voting in part of its GP committee election as it investigates...

Thousands of overseas GPs recognised for 'extraordinary contribution' to NHS

Thousands of overseas GPs recognised for 'extraordinary contribution' to NHS

GP leaders have recognised the extraordinary contribution of thousands of overseas-qualified...

GPs report concerns over BMA GP committee elections

GPs report concerns over BMA GP committee elections

Elections for nearly one in four regional BMA GP committee seats are underway, but...

UK hits 1m second doses of COVID-19 vaccine as campaign shifts to next phase

UK hits 1m second doses of COVID-19 vaccine as campaign shifts to next phase

More than 1m people UK-wide have now had two doses of COVID-19 vaccine, official...

What GPs need to know about the GMC's new guidance on prescribing

What GPs need to know about the GMC's new guidance on prescribing

MDU medico-legal adviser Kathryn Leask explains the key issues GPs need to be aware...