Writing a Good Patient Referral

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Aparna Agrawal*

*Director & Professor, Lady Hardinge Medical College, New Delhi

 

While providing multidisciplinary care to a patient one may need to take help of another specialist. To communicate about this patient with another specialist is a ‘referral’.  Referral is a written order from the primary care doctor to another specialist for a specific medical service. Writing a good, informative and polite referral letter is a special skill. While referring a patient one should follow a certain protocol and should write a self-explanatory referral letter.

The referral could be routine or emergency, it could be from one level to another level of specialist, interval referral, split referral collateral referral or cross-referral. Here we are focusing on interdepartmental referrals of an inpatient in a tertiary care hospital.

It is something that we as medical doctors do day in and day out – but still something somewhere is missing many a times – leading to anger, disappointment and frustration. The fault may lie with either the referring doctor or the specialist to whom the patient was referred to. It could be a very sketchy referral with no/minimal required patient details, the purpose of the referral not having been specified or the urgency of the referral not being mentioned or justified, etc. But please remember that all referrals received must be attended to – as promptly as the situation demands.

Referral writing is an art that we need to master. Here are a few tips to improve referral writing:

1 ) Addressed to: Needs to be clearly specified at the beginning of the referral – whether it is to the duty doctor or consultant and the department or unit to which the patient is being referred to. It can be a general referral or addressed to a particular doctor by name.

2) Basic patient information: Patient details including name, age, sex and hospital registration number, patient’s ward and bed number.

We need to mention

• the date and time of referral (especially for urgent referrals)
• whether it is routine or urgent (justify if urgent)
• is it bedside? (again justify, if yes)
• Name and signature of the referring doctor (usually referrals should go from resident to resident and if we need a consultant referral – it should be signed by a consultant.)

3) Background: Relevant patient history should be written in brief with diagnosis if already established including comorbidities with duration.

4) Situation: Relevant summary of the patient’s presentation and the course in hospital for inpatients. It should be up to date and correct.

5) Assessment: Relevant examination and latest investigation findings.

6) Purpose: This is the most important part of referral writing and needs to be specified very clearly. We may want to refer a patient to another specialist –

          i) after having made a diagnosis that requires specialized care – in addition to primary care being given by the parent department or

          ii) the diagnosis made – warrants treatment which is outside the primary doctor’s field of practice, expertise or available facilities and is the only treatment                    required – write a transfer referral then or

         iii) we need help to determine a diagnosis where we may refer a patient for some specialized tests or investigations or an opinion of an expert in the field                        (needs to be clearly spelt out) or

         iv) to a colleague for second opinion – at patient’s request or for our knowledge, satisfaction and confidence.

A good, properly written referral should provide all the relevant information about the patient and his condition to the specialist being referred to, so that he/she has the relevant background information about the patient, does not have to ask too many questions or flip through the entire case record of the patient plus they know exactly what they are being asked to do. It is always good to make a personal call to the concerned specialist in addition, especially in emergency cases or in cases where the diagnosis is in doubt or we are in a dilemma regarding the patient’s problem. It always helps to improve referral outcome.

I will like to end with a word on referral ethics. Referrals should be made keeping the patient’s best interests in mind – for proper diagnosis, investigations and/or treatment in a timely manner to an appropriate specialist and not to avoid the challenges of a patient with complex problems or a nagging patient or to avoid possible death of a patient with poor prognosis and the consequent effect on the departmental statistics.