Accreditation practice pointer: referral letters
GP2.3 B Our practice’s referral letters are legible and contain all required information.
RACGP Standards for general practice.
Referral letters must be legible and include required information to ensure quality patient care. Referral letters must:
include the name and contact details of the referring doctor and the practice
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 (relevant history, examination findings and current management) 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 (eg the specialist consultancy).
the name of the healthcare provider to whom the referral is being made, if known
any relevant information that will help other healthcare providers deliver culturally safe and respectful care (eg language spoken, the need for an interpreter or other communication requirements).
There must also be a copy of each referral kept in the patient’s health record, for both medico-legal and clinical reasons.
Practices can further support the referral process by:
using a clinical software program to generate referrals that are automatically populated with a health summary
keeping a policy that states referral documents must include at least three patient identifiers (eg their full name, date of birth, and address)
maintaining a procedure for asking patients to consent to referrals being sent electronically
including relevant information about electronic transmission of referrals in the practice’s privacy policy.
