Most of the patients that you see you will manage on your own. A few you will need a second opinion or advice from your trainer, and every once in a while you will have to refer a patient to a different specialty for an opinion or management. The content and style of the referral letters you send may affect the ability of the Consultant to accurately prioritise the patient – and they will definitely give an impression of you as a doctor. This article looks at what makes a good referral letter, and how to answer the three key questions – “should I refer this patient?”, “what do I want to achieve from this referral?” and “where / who should I refer to?”.
The first thing to establish is “does this patient need a referral?”. Over 10% of hospital referrals are inappropriate. Sometimes who you refer will depend on your own confidence in the diagnosis and management of a condition. It may also be affected by the experience of the other doctors in the practice and locally available services – if you or a partner are confident at injecting joints you may do them during a consultation – if not they may be referred. Some doctors refer all skin lesions that require minor surgery, others do a lot of these themselves. It is important to know who has expertise in what in the practice.
Once you have established that a referral is needed, the next question to ask is “what do I want to achieve from the referral?”, as this will help you decide “where should I refer?”. Good knowledge of local services is important here – in some areas you might refer a patient with fibromyalgia to a rheumatologist, where in other areas this might be dealt with by a chronic pain service. A child with suspected autism might be referred to a community paediatrician or a paediatric neurologist, or a child psychologist with a special interest. You trainer will be able to guide you in the early months until you get to know the local services better.
Poor referrals reflect badly on you as a doctor and on your practice. A good letter should include the following:
• Clear identification of patient including name, age, DOB, sex, address and NHS number
• If this is a private referral or an urgent / 2 week wait referral, make it clear at the start
• Presenting problem
• Brief Summary of history
• Treatments already tried and how the patient responded
• Results of investigations and details of pending investigations [to avoid duplication]
• Expectations / reasons for referral are you looking for help with diagnosis? Does the patient need a specific treatment?
• Current drug history and any allergies – you can get this automatically from the Clinical System
The length of the letter requires you to balance the need to provide enough information without becoming tedious to read, yet being so concise that you miss out important relevant information. Over time this balance becomes easier.
Check you haven’t missed any key information, that the letter reads well and that it is signed, dated, and has your contact details.