Purpose

Referral notes communicate the clinical need for specialist input, providing sufficient background for the receiving clinician to triage and manage the referral appropriately.

Key Components

  • Referring and receiving clinician details
  • Urgency level
  • Reason for referral
  • Relevant history and background
  • Examination findings
  • Current medications and allergies
  • Investigations and results
  • Specific question or request
  • Contact details for response

Documentation Tips

  • State the urgency clearly at the top
  • Frame the specific question you want answered
  • Include only relevant clinical information
  • Confirm allergies are included
  • Provide clear contact details for response
Reminder: Always date, time and sign all clinical entries. Include your name and GMC/NMC number.
Template
CLINICAL REFERRAL
=====================================
DATE: _________________________________
URGENCY: Routine / Urgent / Same-day

TO: ___________________________________
Specialty: ____________________________
Hospital: _____________________________

FROM: _________________________________
Grade: ________________________________
Contact: ______________________________
Bleep/Phone: __________________________

PATIENT: ______________________________
DOB: _____________  NHS No: ____________
GP: ___________________________________

REASON FOR REFERRAL:
[Clear statement of the clinical question]

HISTORY:
[Relevant background]

EXAMINATION:
[Relevant findings]

CURRENT MEDICATIONS:
1.
2.

ALLERGIES: ____________________________

INVESTIGATIONS:
[Relevant results]

SPECIFIC REQUEST:
[What you need from the receiving team]

Thank you for seeing this patient.

SIGNATURE: ____________  DATE: _________
NAME (print): __________________________
GMC/NMC No: ___________________________