Referral Letter Structure Pack

Referral letters are high-stakes communication. They need to be clear, complete, and contextually rich enough for the specialist to triage and plan care—without requiring follow-up for basic information.

This structure pack provides templates and writing guidelines to make referral letters consistently excellent.

Core Referral Letter Structure

1. Patient Context (Demographics + History)

• Patient name, DOB, contact details
• Relevant medical history (conditions, medications, allergies)
• Social context if clinically relevant (mobility, living situation, support network)

2. Reason for Referral (The Ask)

• Specific clinical question or request
• Urgency level (routine / semi-urgent / urgent)
• Patient expectations or concerns

3. Clinical Summary (What's Happened)

• Presenting complaint and timeline
• Examination findings
• Investigation results (attach reports if available)
• Treatment to date (what's been tried, what worked/didn't work)

4. Clinical Reasoning (Why This Referral)

• Diagnostic uncertainty or confirmation needed
• Management input required
• Co-management arrangement proposed

5. Next Steps (What You're Asking For)

• Specific investigations or interventions
• Timeline for review
• Communication preferences (copy letter, phone update, etc.)

Specialty-Specific Templates

Cardiology Referral

Use when: Chest pain, arrhythmia, heart failure, pre-op cardiac assessment

Key elements to include:

• Cardiovascular risk factors (HTN, DM, smoking, FHx)
• Exercise tolerance (quantify if possible)
• ECG findings (attach copy)
• Recent echo/stress test results

Dermatology Referral

Use when: Lesion concern, rash, chronic skin condition

Key elements to include:

• Lesion location, size, duration, change over time
• Photos (if available—attach to referral)
• Previous treatments attempted
• Dermoscopy findings (if done)

Orthopaedic Referral

Use when: Joint pain, fracture, surgical consideration

Key elements to include:

• Functional impact (ADLs, mobility, work capacity)
• Imaging (X-ray/MRI—attach reports)
• Conservative management attempted (physio, analgesia)
• Red flags ruled out (infection, malignancy, neurovascular compromise)

Writing Guidelines for Clarity

Do:

• Lead with the clinical question (what you need from the specialist)
• Quantify symptoms where possible ("3 months," "walks 200m," "2 episodes/week")
• Attach investigation results (don't just reference them)
• Be explicit about urgency and patient expectations

Don't:

• Bury the ask in a wall of text
• Assume the specialist has access to your clinical system
• Use ambiguous terms ("recent," "several," "moderate")
• Omit social context that affects management (e.g., living alone, transport issues)

Regenemm Voice Integration

Regenemm Voice drafts referral letters from consult recordings using these templates. The system:

1. Identifies the referral specialty based on discussion
2. Structures content according to specialty template
3. Flags missing critical information (e.g., "No ECG mentioned—attach or note if not done")
4. Formats letter for review and export

Clinicians review, refine, and approve—but the structure and content extraction is automated.

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Want these templates integrated into your Regenemm Voice setup? Contact us to customize templates for your service.