Importance

Referrals are an essential part of hospital medicine. How you make a referral reflects on you, your team, and the quality of care your patient receives. Understanding not only how to refer, but also when and in what context, will help you become a safe and effective doctor.

Contexts in Which Referrals Are Made

Referrals can occur in several different situations, each with slightly different etiquette and urgency:

1. Emergency referrals
   • For unstable patients needing immediate specialist input (e.g. STEMI to cardiology, ruptured AAA to vascular).
   • Usually by direct phone/bleep to the on-call registrar/consultant or via an emergency pathway.
   • Documentation and escalation should be simultaneous, not sequential.
2. Urgent inpatient referrals
   • For patients who are stable but need to be reviewed promptly (same day or within hours).
   • Example: new hemiparesis → stroke team, new GI bleed → gastroenterology
3. Routine inpatient referrals
   • For non-urgent specialty input while a patient is admitted.
   • Example: dermatology review for chronic rash, orthopaedics for stable fracture.
4. Outpatient referrals
   • Often arranged at discharge, either by the inpatient team or later by the GP.
   • These are typically done electronically and require a clear indication, supporting information, and clinic choice.
5. GP-to-hospital referrals
   • These are usually managed through centralised systems (e.g. NHS e-Referral Service) or via direct communication in urgent cases.
   • GPs may also send patients straight to ED in urgent cases – a referral letter is often given to the patient to take.
6. Ward-to-ward or team-to-team transfers
   • “Referral” in this sense may mean a transfer of care, e.g. from acute medicine to a specialty ward once the diagnosis is clearer, or from surgical teams to a medical team once there are no surgical issues remaining and only medical issues are keeping the patient in hospital.
   • Clarify whether it’s a full takeover of care or just an advisory role.
7. Internal advice vs. formal referral
   • Sometimes you just need a quick discussion/advice call (“Would you manage X this way?”).
   • Other times a full formal referral is needed for review. Knowing the difference prevents unnecessary specialty involvement but ensures patients are not missed.

Before Referring

1. Be clear on the purpose of your referral
   • Are you seeking advice, requesting admission/takeover of care, or arranging outpatient follow-up?
   • Having a clear, focused question in mind helps the receiving specialty respond appropriately.
2. Consult local guidelines and pathways
   • Many specialties have specific referral criteria, pathways, or proformas (sometimes electronic).
   • Check whether your hospital requires referrals via:
     • Online portal / electronic system (e.g. EPIC, cerner)
     • Direct extension or via switchboard
     • Bleep
     • Or a mix, depending on the specialty, urgency of the case, and time of day
3. Complete the necessary work-up
   • Ensure the patient has had initial investigations and management appropriate to their presentation.
   • For example:
     • Chest pain → ECG, troponins, CXR, analgesia
     • Abdominal pain → bloods, urine dip, imaging if indicated
   • Stabilise the patient before referral. If unstable, escalate immediately (e.g. CCOT review, crash call).
4. Know your patient
   • Have to hand: name, age, sex, hospital/NHS number, location.
   • Review their notes so you can confidently present the history, comorbidities, allergies, DNACPR/TEP status, and what has been done so far.
   • Be ready to answer likely questions from the receiving team (e.g. “What are their most recent bloods? Are they anti-coagulated? What is their functional status?”).

During the Referral

1. Introduce yourself clearly
   • State your name, grade (e.g. FY1), team/firm, and where you are calling from.
2. Use a structured format (SBAR works well):
   • Situation – Identify the patient, their current issue, and the reason for referral.
   • Background – Brief history of presenting complaint, relevant comorbidities, and events leading up to referral.
   • Assessment – Pertinent clinical findings, recent observations, key results from bloods/imaging, and your impression. Mention ceilings of care/TEP status if relevant.
   • Recommendation – What you are asking for: advice, review, admission, procedure, or follow-up. Always ask if there is anything you should do in the meantime.
3. Be concise but thorough
   • Keep to the key points and avoid long, unfocused histories.
   • Equally, don’t omit essential information — a clear, balanced summary is most effective.
4. Professionalism
   • Stay polite and respectful, even if the referral is declined.
   • Avoid phrases like “my reg told me to call” without context — instead, explain the clinical reasoning.
   • If you feel the advice given is unsafe, escalate to your senior.

After the referral

1. Document thoroughly in the notes
   • Who you spoke to (name and grade)
   • Time and date of the conversation
   • The advice given and any agreed plan
   • Whether the specialty will review or take over care
   • If referral was declined, the reason provided
2. Act promptly on recommendations
   • Prescribe, request investigations, or escalate as directed.
   • Ensure urgent actions (e.g. IV antibiotics, fluids, imaging) are not delayed.
3. Escalate concerns
   • If advice does not seem safe, discuss with your registrar/consultant.
   • Patient safety always takes precedence over “just following instructions.”
4. Follow up and close the loop
   • Check that the referral has been actioned (especially if via electronic system).
   • Update the patient and their family where appropriate — referrals can be stressful for them too.

Extra Tips for Good Practice

Extra Tips for Good Practice

• Timing matters – avoid non-urgent referrals out of hours if it can safely wait for the daytime team.
• Clarity of responsibility – confirm whether the specialty is now taking over care, reviewing only, or just advising.
• Respect specialty boundaries – if unsure who is appropriate, ask your senior before calling.
• Face-to-face etiquette – if a specialty comes to review your patient, be available to hand over, thank them, and ensure they can easily access notes and results.