Do you write medical referrals?

Medical Referral Writing

I do not write medical referrals myself, but I can provide evidence-based guidance on how healthcare providers should write effective medical referrals.

Essential Components of an Effective Referral Letter

A medical referral should be a structured, concise communication that includes specific clinical information to facilitate optimal patient care. 1

Required Structural Elements

• Use a structured format rather than unstructured narrative letters, as 91% of referring physicians prefer this approach 2
• Keep the letter brief while including all essential information 2
• Include problem lists to organize clinical information 2
• Maintain HIPAA-compliant confidentiality in all communications 1

Critical Content Requirements

Prioritize diagnostic insight over data elements - referring physicians value diagnosis, prognosis, and management plans far more than detailed histories or medication lists 2

Mandatory Information to Include:

• Reason for referral stated explicitly (evaluation, surgery, or specific concern) 1

• Duration of the condition being referred 1

• Relevant clinical history including:

  • Previous diagnostic test results (hearing tests, tympanometry, imaging) 1
  • Treatment history and response 1
  • Comorbid conditions that may affect management 1
  • Developmental status (when relevant) 1

• Current functional status and how symptoms impact quality of life 1

• Patient's understanding and preferences regarding potential interventions 1

Specialty-Specific Referral Requirements

Cardiac Rehabilitation Referrals

Document official communication with the patient recommending the program AND either send an official referral order to the CR program OR document patient refusal 1

• Include cardiovascular history, testing results, and treatments 1
• Transmit all patient enrollment information to the CR program 1
• Make referrals prior to hospital discharge for qualifying events (MI, CABG, PCI, valve surgery) 1

Nephrology Referrals

Refer patients with eGFR <30 mL/min/1.73 m², significant albuminuria (>1 g/day), or rapid decline in kidney function (>5 mL/min/1.73 m² per year) 3

• Document specific kidney function trends (baseline and current eGFR values) 3
• Include proteinuria quantification and urinalysis findings 3
• Note blood pressure control status and number of antihypertensive agents 3
• Specify any hereditary kidney disease or systemic conditions 3

Oncology Rehabilitation Referrals

Refer patients experiencing treatment-related symptoms impairing function at any point during cancer care 1

• Specify symptom burden (fatigue, pain, lymphedema, cognitive dysfunction) 1
• Document functional limitations in activities of daily living 1
• Include cancer type, stage, and treatment modalities received 1
• Note any high-risk surgical procedures planned 1

Lymphedema Referrals

Refer patients with clinical symptoms or swelling suggestive of lymphedema to a certified lymphedema specialist, physical therapist, or occupational therapist with lymphedema training 4

• Document laterality and anatomic distribution of swelling 4
• Include history of lymph node dissection or radiation therapy 4
• Note any history of infections or cellulitis 4

Common Pitfalls to Avoid

Do not rely solely on verbal instructions - written documentation is essential for continuity of care and medicolegal protection 5

Avoid incomplete medical histories - studies show referral letters are only 58.8% complete on average, with 70.4% missing at least one relevant finding 6

Do not assume the specialist will take a complete history - incomplete referrals lead to delayed diagnoses, polypharmacy, and unnecessary testing 5

Ensure legibility - handwritten referrals with poor clarity create significant communication barriers 5

Practical Implementation Strategy

Use structured referral templates or form letters to improve information content, save time, and enhance communication quality 5

• Templates ensure all required fields are addressed systematically 5
• Structured formats facilitate information retrieval by specialists 5
• Form letters have demonstrated improved communication in the referral process 5

The ideal referral letter informs without patronizing, educates without lecturing, directs without ordering, and solves the problem without making the referring physician appear uninformed 7