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 accurate and thorough. 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 (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).

There must be a copy of each referral letter in the corresponding patient health record. In unusual circumstances, referrals may be made via telephone. Likewise, the details of the telephone referral must be documented in the patient’s health record.

Should a referral need to be emailed, the RACGP has developed a matrix  that advises general practice the necessary information to send to patients or other healthcare providers.

Practices can ensure referral letters are completed appropriately by:

• using a clinical software program to generate referrals that are automatically populated with a health summary

• having a policy that states referral documents must include at least three patient identifiers (eg. their full name, date of birth, and address)

• having 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.