Physician Referral Letter and Consult Note

Primary care doctors and specialists disagree about how often the reason for a referral gets through. In a 2008 national survey of 4,720 US physicians, 69.3% of primary care physicians said they always or most of the time sent the history and reason for consultation¹. Only 34.8% of specialists said they received it that often.

The referral checklist from the American College of Physicians (ACP) asks for the specific clinical question, with a brief summary of the most relevant clinical information². Put the question in the first line and name the decision you face: whether to start, stop, test, operate or wait. If there are two questions, number them, the more important first, so the reply can answer each by number.

Next, say what kind of help you want. Advice is a different job from taking over a condition. ACP's checklist has you choose one of seven referral types², from advice before a visit to a complete transfer of care.

Then say how soon. ACP's checklist uses three levels: urgent (often 1 to 2 days), subacute (often 1 to 2 weeks) and routine, with exact timing set locally. For an urgent referral, it recommends direct contact between the two practices and a written reason for the urgency.

Everything after the question should help the specialist answer it. ACP calls this the pertinent data set: clinical information directly relevant to the referral question², such as the latest visit note and relevant labs and imaging. Always add current medications and allergies, plus anything that changes how the visit runs, such as hearing loss or the need for an interpreter.

List what has been tried, with start and stop dates and why each was stopped, or the specialist may restart a drug that failed. If a date isn't in the record, write "date not documented" rather than guess. Visit notes in a consistent SOAP format make this quick to pull.

Attach the full notes rather than pasting them in. In the US, HIPAA permits sharing records with another provider for treatment, and its minimum necessary standard does not apply to disclosures to a health care provider for treatment³. What limits the letter is the reader's time.

If you're the specialist, your consult note is the answer, and it doesn't always arrive. In the same 2008 survey, 80.6% of specialists said they always or most of the time sent results back to the referring doctor¹. Only 62.2% of primary care physicians said they received them.

Goldman and colleagues' 1983 ten commandments for effective consultations⁴ still work as a checklist. Determine the question being asked, communicate as briefly as appropriate and make specific recommendations. Provide contingency plans, and give your recommendations directly to the clinician who asked.

Answer each question first, numbered to match the referral. Then cover the main points of ACP's model referral response checklist⁵:

• Diagnoses confirmed, ruled out or still suspected
• Medication changes, and whether you made them or the referring clinician should
• Tests still pending, and who follows up each one
• Any new problem you found, and who takes it on
• Follow-up, with a time frame and whether it's scheduled

ACP suggests the note reach the referring clinician within a week of the visit, if not sooner. If the referral asked nothing specific, say in your first line what you took the question to be, so the referring office can correct you.

Patients need any change of plan in plain words too, and a patient education handout can explain the condition itself.

Before you send it, check the patient's health plan. HealthCare.gov notes that in many HMOs, the plan may not pay for specialist care without a referral⁶ from the primary care doctor. Some tests and procedures also need the plan's approval in advance, through a prior authorization request.

Follow the referral until it's answered. A 2018 study of one large US health system analyzed 103,737 attempts to schedule referrals from primary care to 20 specialties. Only 34.8% resulted in a documented, completed appointment⁷, and 38.9% had no appointment date recorded.

Log each referral's date sent, question, appointment date and the date the answer arrived. Chase any with no appointment, and any answer still missing a week after the visit.

To start from notes you already have, paste them into the tool at the top of this page. It drafts the letter with the question first, or the reply in the referral's numbering, and marks gaps for you to confirm.