Clinical documents
Writing a referral letter
A referral letter asks a colleague a specific question and gives them what they need to answer it. State the question in the first lines, give the relevant history, results and medications with dates, say what you have already done and how urgent it is. A letter that does this gets triaged correctly and saves the patient a repeat workup.
The Workup Desk team. Last reviewed November 3, 2026. General guidance on clinical documentation, not medical advice about any individual patient.
Ask one clear question
Put the question in the first two lines. Please assess for chronic coronary syndrome and advise on further investigation is a question. Please see and advise is a request to start again.
When you have more than one question, number them. The receiving doctor can then answer each in turn, and you can see which ones were answered.
Give the history the receiver needs
Include the presenting complaint with its timeline, the relevant past history, current medications with doses and any allergies. Leave out history that does not bear on the question.
Record the risk factors that change triage. Smoking with pack-years, family history of early disease and the duration of symptoms often decide how soon a patient is seen.
Quote results with dates and units
Quote the results that bear on the question with their values, units and dates. A specialist reading LDL 159 mg/dL from last week can act on it. A specialist reading elevated cholesterol cannot.
Attach or name the full reports for imaging and ECGs, and quote the reporter's conclusion. Do not paraphrase a report into a stronger or weaker statement than the reporter made.
| Element | Why it matters | Example |
|---|---|---|
| The question | Decides who triages it and what they answer | Assess for chronic coronary syndrome |
| Urgency and reason | Lets the receiver book the right slot | Routine, symptoms stable for six weeks |
| Relevant history | Saves the receiver retaking it | Exertional chest pain, mediastinal radiotherapy in 1992 |
| Results with dates | Avoids repeat tests | hs-troponin T 6 ng/L, LDL 159 mg/dL |
| What you have done | Shows what is left to try | Started statin discussion, ECG done |
| What the patient knows | Prepares the first conversation | Aware referral is to exclude heart disease |
Say what you have already done
List the investigations you have arranged and the treatments you have started or stopped. The receiving doctor needs to know whether a test is pending or still to be ordered.
Say what you would like the receiver to take on and what you will keep. Shared care works when both sides know who prescribes, who monitors and who follows up results.
State the urgency and the safety net
Choose the urgency your local referral pathway defines and give the reason in one line. If the patient meets criteria for an urgent pathway, say which.
Record the safety-netting advice you gave while the patient waits. If symptoms change, the patient and the receiving team both know what you told them to do.
Tell the receiver what the patient knows
Say what you have told the patient about the reason for referral and what they expect. A specialist who knows the patient fears cancer starts a different conversation from one who does not.
Note any communication needs, such as an interpreter, a caregiver who attends or a preference for written information.
Draft from the workup and edit
A referral letter is a shorter version of your assessment, written for one reader and one question. When the sources and your assessment are already in one place, you can draft the letter from them and edit it.
Check every result and dose in the draft against its source before you send it. The receiving doctor will act on the numbers you quote.
Questions to check in your own work
- 1.Is the question in the first two lines?
- 2.Have I quoted every relevant result with its value, unit and date?
- 3.Does the letter say which tests are pending and which are still to order?
- 4.Have I stated the urgency and the reason for it?
- 5.Does the receiver know what the patient has been told?
Common questions
How long should a referral letter be?
Usually one page. Long enough to answer what the receiver needs to triage and act, and no longer. Attach full reports rather than copying them in.
Should I include my differential diagnosis?
Yes, briefly. Your working diagnosis and the alternatives you are worried about help the receiver triage the letter and focus the first appointment.
What if my local pathway has a referral form?
Use the form. The same principles apply to the free-text fields, and the question still belongs at the top.
Try it on one patient's documents
Keep each patient's sources in one workspace, ask questions of them, and draft documents you edit and export. Early access is by invitation.