GP to specialist referral template

Australian documentation guide

A referral body that sets out the question for the specialist, relevant clinical context, investigations, medicines and the referrer's stated urgency. Patient, recipient and sender details must be supplied separately in the record system.

The blank template

REASON FOR REFERRAL: [ ]
CLINICAL SUMMARY: [ ]
RELEVANT EXAMINATION FINDINGS: [ ]
INVESTIGATIONS: [ ]
CURRENT MEDICATIONS: [ ]
ALLERGIES & ADVERSE REACTIONS: [ ]
RELEVANT PAST HISTORY: [ ]
SOCIAL CONTEXT: [ ]
URGENCY / TRIAGE: [ ]

How to fill it in

Copy the blank template into your record system.
Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Reason for referral

Establish the referring clinician’s question or requested assessment and the person’s relevant preference. State why this referral is being made now. “Advice requested”, “assessment requested” and “transfer of care requested” imply different responsibilities.

Clinical summary

Summarise the relevant history and course, distinguishing reported symptoms from diagnoses actually established. Attribute outside records and preserve uncertainty. Do not make a referral more definitive by converting a working impression into a confirmed diagnosis.

Relevant examination

Record findings actually obtained that are relevant to the referral, including site, side, date or measurements when available. Identify examination limitations. An unexamined finding must not be described as normal merely because the letter is concise.

Investigations

List relevant investigations and their known dates, results and status. Distinguish ordered, collected, pending and reported. State whether an attachment is included when established; a mention of a result is not proof that it accompanies the letter.

Current medications

Record medicines relevant to the referral and identify the source and currency of the list. Include established name, strength, dose, route and frequency. A prescribed item and a person’s reported current use may differ; keep that difference visible.

Allergies and adverse drug reactions

Record the known substance, reaction and source or uncertainty. Distinguish no known allergy from a history not obtained. Do not invent a reassuring default or reclassify a disputed reaction.

Relevant past history

Include established history that helps answer the referral question, with timing where known. Separate resolved events, ongoing conditions and family history. A copied list does not establish that all entries were reassessed for this referral.

Record relevant context actually discussed, such as communication needs, available support or access constraints. Attribute the person’s account and preferences. Avoid assumptions about capacity, adherence or social risk.

Urgency and triage

Record only urgency explicitly assigned by the referring clinician and the reasons they stated. Distinguish an urgent request, a routine request and urgency not stated. This field does not calculate urgency or direct a receiving service’s triage decision.

Common omissions

The precise referral question, pending results, attachment status and who retains follow-up responsibility are easy to lose. Check names, recipient and contact information in the letter workflow rather than guessing them from context.

Review before sending

Check that the recipient can identify the request, evidence and unresolved information. Confirm that urgency is source-supported, the medication and reaction information is accurately attributed, and stated enclosures are present. Follow local consent, referral and secure-communication procedures.

Worked examples

A referral for a recorded hearing concern

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: Referring GP requests ENT assessment of persistent right-sided hearing difficulty. The question is whether specialist investigation is needed.
CLINICAL SUMMARY: Person reports three months of intermittent difficulty hearing speech on the right. No ear pain or discharge reported. No acute change is reported in the fictional encounter.
RELEVANT EXAMINATION FINDINGS: GP records clear external canals and normal-looking tympanic membranes on otoscopy. No formal hearing assessment was performed at the visit.
INVESTIGATIONS: No audiogram or other investigation is available with this referral.
CURRENT MEDICATIONS: Person reports no regular medicine. The list has not been independently reconciled for this referral.
ALLERGIES & ADVERSE REACTIONS: Person reports no known medicine allergy; reported status is identified as such.
RELEVANT PAST HISTORY: Person reports no previous ear surgery. Other history relevant to the referral was not identified in this focused encounter.
SOCIAL CONTEXT: Person works in an open-plan office and describes difficulty following conversation. They request written appointment details.
URGENCY / TRIAGE: Routine referral, as explicitly recorded by the referring GP.

A referral request with important details still absent