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Hospital and emergency department referral template

Australian documentation guide

A hospital or ED referral body grounded in the referring clinician's assessment. It documents the request without calculating urgency or claiming that clinical handover has occurred.

The blank template

How to fill it in

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

Reason for referral

Lead with the referring clinician’s request and the intended hospital service. State the concern in their own terms, preserving a working impression as a working impression. A clear opening helps the receiving team find the request without turning an uncertain presentation into a confirmed diagnosis.

Presenting problem

Describe the symptoms, timing and course actually recorded, along with relevant history and any actions already taken. Keep the person’s account distinct from the clinician’s assessment. Retain clinically relevant detail somewhere in the letter rather than dropping it to make the opening shorter.

Relevant examination findings

Include findings obtained at this assessment, with the site, side and time where available. Say if an examination was limited or not performed. Do not fill gaps with normal findings or copy an earlier examination as though it happened today.

Vital signs

Record the measurements available, with units and timing. Include relevant context such as oxygen being used when documented. A number cannot supply its own clinical interpretation, and a missing measurement is not a normal measurement. Leave unrecorded information visible for review.

Current medications

Include the available medicine history and its source, including recent doses when recorded. Keep unknown dose or timing explicit. Do not infer a medicine from a diagnosis or add treatment advice to complete the letter.

Allergies and adverse reactions

Document the known substance and reaction, with the source and any uncertainty. If this required history is unavailable, use [not stated]. Do not replace an unasked allergy history with “no known allergies”.

Urgency

Use only the urgency the referring clinician explicitly assigned and the reasons they recorded. Do not calculate it from symptoms or vital signs. If urgency was not stated, leave [not stated]; this template does not make a triage decision for either team.

Common omissions

Check for missing assessment times, investigation status, recent treatment and what has actually been communicated to the receiving service. A referral letter, a phone handover, a transport arrangement and acceptance of care are separate events; record each only when established.

Review before sending

Confirm that the request, evidence and remaining uncertainty are easy to find. Check the clinician’s stated urgency, identifiers, recipient, medicines, reactions and available enclosures. Follow the clinician’s actual referral and communication arrangements; preparing or sending this letter does not establish completed handover or escalation.

Worked examples

An urgent referral with recorded findings and uncertainty

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: The GP requests emergency department assessment of worsening abdominal pain. The cause remains uncertain in the referring GP's assessment.
PRESENTING PROBLEM: The person reports pain beginning yesterday evening and becoming more intense this morning, with two episodes of vomiting. They report that they have not previously had similar pain. The GP documents that hospital assessment was discussed with the person.
RELEVANT EXAMINATION FINDINGS: At 10:20 the GP records right lower abdominal tenderness. No further examination findings are stated in this fictional encounter.
VITAL SIGNS: At 10:20: temperature 38.1°C, pulse 104 beats/minute, blood pressure 118/74 mmHg, respiratory rate 18 breaths/minute and oxygen saturation 98% on room air.
CURRENT MEDICATIONS: The person reports no regular medicines and states they took one dose of paracetamol this morning; the strength and dose are not stated.
ALLERGIES & ADVERSE REACTIONS: The person reports no known medicine allergy. This is reported history.
URGENCY: Urgent ED assessment requested, as explicitly documented by the referring GP. The extract does not record transport arrangements, direct contact with the ED or acceptance of handover.

A referral draft with urgency and key information absent

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: Hospital assessment was discussed. The requested service and specific referral question are not stated in this extract.
PRESENTING PROBLEM: The person describes a recent deterioration in symptoms; their nature and timing are not recorded here.
RELEVANT EXAMINATION FINDINGS: [not stated]
VITAL SIGNS: [not stated]
CURRENT MEDICATIONS: [not stated]
ALLERGIES & ADVERSE REACTIONS: [not stated]
URGENCY: [not stated]

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.