What are the key components to include when writing a referral letter?

How to Write a Referral Letter

A high-quality referral letter should include patient demographics, relevant medical history with current medications, examination findings, reason for referral with specific clinical question, and complete contact information—preferably using a structured electronic template rather than handwritten format. 1

Essential Components of Every Referral Letter

Mandatory Information

• Patient identification: Full name, date of birth, contact information 2
• Referring provider details: Name, practice address, phone number, and email for direct communication 1
• Date of referral and urgency level: Clearly state if urgent consultation is needed 3
• Primary diagnosis or reason for referral: State the specific clinical question you need answered 1

Clinical Content Requirements

• Relevant medical history: Include pertinent past medical conditions, not exhaustive lists 2, 3
• Current medications with dosages: Complete and accurate medication reconciliation 4, 3
• Allergies and adverse drug reactions: Document all known allergies 4
• Examination findings: Include vital signs and relevant physical exam findings, especially for urgent referrals 3
• Investigation results: Attach or summarize relevant laboratory values, imaging, or test results 5, 2
• Previous treatments attempted: Document what has already been tried and the response 6

Additional High-Value Information

• Psychosocial factors: Include relevant social history, barriers to care, or family concerns that may impact treatment 5, 2
• Patient's understanding and preferences: Document what the patient knows and expects from the referral 1
• Functional status: Describe impact on daily activities (home, work, school) 1, 4
• Specific goals of referral: Be explicit about whether you need diagnosis, treatment recommendations, or co-management 1

Format and Delivery Method

Use electronic or computer-generated templates rather than handwritten letters—they are more legible, complete, and contain fewer errors. 3, 7

Advantages of Structured Templates

• Standardized templates ensure completeness: Form letters contain more information than free-text letters while being shorter 7
• Electronic systems improve documentation: Computer-generated letters are more likely to include accurate medication lists and medical history 3
• Templates increase awareness of risk factors: Structured formats prompt inclusion of critical information that might otherwise be omitted 2, 6

Communication Standards

• Maintain HIPAA compliance: All communications must protect patient confidentiality 1
• Use clear, jargon-free language: Avoid unnecessary medical terminology, but when technical terms are required, consider including brief explanations 5
• Ensure bidirectional communication: Provide mechanism for specialist to respond with recommendations 6

Cardiac Rehabilitation Example (Specific Application)

For cardiac patients requiring rehabilitation referral, the letter must include: 1

• Qualifying diagnosis: MI, CABG, PCI, valve surgery, or cardiac transplantation
• Cardiovascular history: Complete cardiac testing and treatment history
• Contraindications to exercise: Document any high-risk conditions
• Patient discussion: Confirm patient has been counseled about CR program benefits
• Referral order: Send official referral to specific CR program with all necessary enrollment information

Genetic Services Referral (Specific Application)

When referring for genetic consultation: 1

• Family history documentation: Include detailed pedigree information and cancer history
• Risk assessment: Document why patient meets criteria for genetic evaluation
• Patient knowledge and concerns: Note what patient understands about genetic testing
• Barriers addressed: Document discussion of emotional, social, or financial concerns

Common Pitfalls to Avoid

• Incomplete medication lists: This is one of the most frequent deficiencies—verify current medications before sending referral 3
• Missing examination findings: Over 50% of referrals lack physical exam data, which is critical for specialist assessment 3
• Vague reason for referral: Avoid "please see and advise"—state specific clinical questions 6
• Handwritten letters: These have poor legibility and lower quality; abandon this practice entirely 3
• Omitting test results: Failure to include relevant laboratory or imaging results delays care 2
• No follow-up plan: Specify expected timeframe for consultation and who will coordinate ongoing care 4

Quality Improvement Strategies

Implement peer feedback systems and combined intervention packages to achieve sustained improvement in referral quality. 6

• Use referral templates or checklists: These increase documentation completeness by ensuring all key elements are addressed 2, 7, 6
• Regular peer review: Feedback from specialists can reduce inappropriate referrals by up to 50% 6
• Patient questionnaires: Consider having patients complete standardized forms to capture information that may be missed in provider letters—this adds relevant information in 57% of cases 2
• Electronic referral systems: These provide advantages over paper but require attention to new barriers they may create 6