vstorm-co Drafting a referral
A referral is rejected for missing information far more often than for clinical reasons. The job is completeness.
The structure
Reason for referral · relevant history · current medications · allergies · examination findings · investigations already done, with dates and results · what is being asked of the receiving service · urgency, with the reason for it.
Mark the gaps, loudly
Any field the record cannot fill goes in as [MISSING: …] rather than being
omitted or softened. A referral that looks complete and is not wastes a
rejection cycle and a fortnight of the patient's time.
Urgency
State the criterion that makes it urgent, not the word alone. "Two-week pathway: unexplained weight loss with a palpable mass" survives triage; "urgent" does not.
Never
Infer a finding that is not documented, carry forward an investigation result without its date, or set an urgency the notes do not support.