As a primary care doctor, an important part of my working day is writing referrals. And when my clinic is busy, it’s easy to be tempted into writing a quick referral like this:

Dear Gastroenterologist,

Thank you for seeing Ms AB a 45-year-old female with GORD.

Kind Regards,
Dr AH

A referral with such brevity of information is neither helpful to your patient nor the specialist you are referring to! But don’t be fooled: the length of a referral letter is not directly proportional to an increase in quality!

Don’t overdo it

Check this one:

Dear Gastroenterologist,

Thank you for seeing Ms AB a 45-year-old female with epigastric pain. She has had six months of epigastric pain which she describes as a gnawing sensation. She rates this pain 6/10 and it occurs after most meals, lasting for one hour. It is worse after eating tomato-based foods and when she is stressed. The pain is relieved after drinking milk.

The epigastric pain initially started when she separated from her husband six months ago and moved house. She does not have any associated reflux, retrosternal burning, throat pain, nausea, vomiting, diarrhoea, constipation, fevers, night sweats, anorexia, loss of weight, dyspnoea, orthopnoea, cough, chest pain or jaw pain. Please see details of her past medical history below.

On examination today, her general appearance was unremarkable. Her observations: HR 65, RR 20, Temp 36.4, BP 122/84, O2 98% RA, GCS 15, BSL 5.3. She did not have any palmar erythema, clubbing or nicotine stains on examination of her hands. Examination of her face was normal.

She had dual heart sounds, no heaves, thrills or murmurs. She had good air entry in her right and left lobes posteriorly. Her abdomen was soft with epigastric tenderness. There was no guarding or rebound tenderness. Her bowel sounds were present. Her digital rectal exam was normal. I have arranged for an abdominal ultrasound and a H. Pylori breath test today. My provisional diagnosis is gastro-oesophageal reflux disease. Thank you for seeing this patient.

Kind Regards,
Dr AH

Issues

This referral letter is way too lengthy and is filled with superfluous information! It also doesn’t really outline the reason for the referral. An effective referral letter is vital so your patient can be triaged and reviewed appropriately.

Things to include in your referral

Make sure your letter includes the basics:

• Up to date and correct patient information.
• Relevant medical history.
• Current medications and any allergies.
• Your details as the referring doctor.

The Royal Australian College of General Practitioners Standards for General Practice also outline that referral letters must:

• Include the name and contact details of the referring doctor and the practice
  be legible.
• Include the patient’s name and date of birth, and at least one other patient identifier.
• Explain the purpose of the referral.
• Contain enough information so that the other healthcare provider can provide appropriate care to the patient.
• Not include sensitive patient health information that is not relevant to the referral.
• Include a list of known allergies, adverse drug reactions, and current medicines.
• Identify the healthcare setting to where the referral is being made.

Using ISBAR for your referral letters

I find having a structure for effective referral letters really helpful. I like using ISBAR, just like you use in a clinical handover or phone call.

1. Information

• Up to date and correct patient information.
• Your details as the referring doctor.

2. Situation

• Relevant summary of the patient presentation.

3. Background

• Relevant medical history.
• Current medications and any allergies.

4. Assessment

• Relevant examination and investigation findings.

5. Request

• Purpose of the referral.
  

Using this framework, let’s see if we can improve Ms AB’s referral.

A good example of a referral

Ms GI
Gastroenterologist
13 Abdominal Avenue
Sydney NSW 2000

Dear Ms GI,

[Information]
RE: New Referral
Ms AB, DOB 01/01/1975
65 Tummy Terrace, Sydney, NSW 2000

[Situation] Thank you for seeing Ms AB a 45-year-old female with difficult to control gastro-oesophageal reflux disease for your consideration of a gastroscopy. [Background] She has had 6 months of worsening epigastric pain, worse after meals. She has not displayed any constitutional symptoms during this time. Her medical history includes obesity and a cholecystectomy in 2016. She is currently on 40mg esomeprazole daily and doesn’t have any allergies.

[Assessment] The only finding on physical examination is epigastric tenderness on palpation of her abdomen. Her most recent liver function tests (dated 1/3/2020) and upper abdominal ultrasound (dated 1/2/2020) were normal. A H. Pylori breath test (dated 1/3/2020) was negative. For the past 6 months she has been managed with 40mg esomeprazole daily. She has also modified her diet and been trying to lose weight.

[Request] Despite this her symptoms persist and I would greatly appreciate your clinical review and consideration of a gastroscopy to confirm this diagnosis and ensure nil other pathology contributing to her symptoms.

Kind Regards,
Dr AH
Sydney Primary Practice
Sydney, NSW 2000

Resources for improving your writing skills

Next time you are writing a referral letter, try using the ISBAR structure! Improving your referral letter writing skills not only improves inter-professional communication but ultimately patient care!

If you’d like to read more, check out these great resources:

• Clear communication – RACGP referral writing
• Referring to other medical specialists – RACGP A guide to ensuring good referral outcomes for your patients
• GP Referral letters
• GP Communication – The right letter RACGP