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Specialist cross-referral letter template

Australian documentation guide

A specialist-to-specialist referral body. It records the referring clinician's question, findings and stated urgency; actual referral particulars belong in the sending system.

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

Name the specialty or service requested and the question the referring clinician wants answered. Include the person’s priorities when documented. A particular provider can be named when chosen; do not invent one to complete the draft. Distinguish advice requested from an agreed transfer of care.

Clinical summary

Give enough context for the colleague to understand the concern and the course so far. Preserve the difference between symptoms, working impressions and established diagnoses. Identify outside information and relevant care already underway rather than making every statement sound newly assessed.

Relevant examination findings

Include the findings actually obtained, with dates, measurements or limitations where relevant. Leave an unperformed examination as unperformed. A referral to another specialty does not establish findings that only that specialty would assess.

Investigations

List the investigations relevant to the question and their known status. Keep requested, pending and reported results distinct. Check actual enclosures before saying they are attached. If the report is absent, retain that limitation rather than filling in a likely result.

Current medications

Record the available medicine list and when and how it was obtained. Keep established directions precise. Make discrepancies or missing information visible rather than silently choosing between the person’s account and an older prescription list.

Allergies and adverse reactions

Include the substance, reaction and source when known. Preserve uncertainty about an old or disputed reaction. If the required history was not obtained, write [not stated]; that does not mean the person has no allergies.

Urgency and triage

Record urgency explicitly assigned by the referring specialist, with any stated reason. Do not derive a triage category from the specialty, symptoms or investigations. This request also does not determine the receiving service’s own triage decision.

Common omissions

Check for a vague referral question, a pending result with no owner and unclear communication with the person’s GP. Record who is following up when agreed. A referral request does not by itself show that another clinician has accepted care.

Review before sending

Read the letter for a colleague meeting the person for the first time: is the question clear, with enough evidence to understand it? Verify recipient, consent, identifiers, enclosures and actual date and signature in the sending workflow. Check applicable referral requirements separately; do not assume a referral period from this template.

Worked examples

A focused request for another specialty's assessment

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 respiratory specialist requests ENT assessment of persistent hoarseness. The person agrees to the referral and would like the assessment to clarify the cause of the voice change.
CLINICAL SUMMARY: The person reports hoarseness for three months, affecting their work as a teacher. The respiratory specialist records that no cause has been established at this consultation. The GP will receive a copy of this letter.
RELEVANT EXAMINATION FINDINGS: The specialist describes the voice as hoarse during conversation. No laryngeal examination was performed at this visit.
INVESTIGATIONS: No investigation result relevant to the hoarseness is recorded in this fictional encounter. No enclosure is described.
CURRENT MEDICATIONS: The person reports no regular medicine. The source is the person's account at today's visit.
ALLERGIES & ADVERSE REACTIONS: The person reports no known medicine allergy; this has not been independently checked.
URGENCY / TRIAGE: Routine referral, as explicitly assigned by the respiratory specialist. Their practice will track the referral response; the receiving service has not yet confirmed an appointment.

A cross-referral draft with the question and triage still missing

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: Another specialist's advice is requested. The receiving specialty and precise question are not stated in the extract.
CLINICAL SUMMARY: Earlier clinic correspondence is available, but no current summary has been documented here.
RELEVANT EXAMINATION FINDINGS: [not stated]
INVESTIGATIONS: A report is mentioned in the notes; its findings and enclosure status are not stated.
CURRENT MEDICATIONS: [not stated]
ALLERGIES & ADVERSE REACTIONS: [not stated]
URGENCY / TRIAGE: [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.