Two kinds of referral letters:

1. To the medical practioner requesting assessment of the current status of the patient (this is required in the case of medically compromised patients before doing invasive procedures, for eg, Referral of a diabetic patient before periodontal surgery)

2. To the dental specialist, requesting assessment or treatment. (For eg, request to an Oral and Maxillofacial Surgeon for management of suspected mucocele!)

The following is a guide to write referral letter to a Dental Specialist.

Sample format of referral letter to the Dental Specialist

Introductory Section:

Referring Practioner Details:

1.     Name of Referring doctor:

2.     Complete Practice Address: (with postcode)

3.     Telephone Number: (if available)

4.     Fax Number: (if available)

5.     Email Id: (if available)

Referral Letter To:

1.     Complete details of the consultant/practioner/hospital:

2.     Name of consultant/receiving practioner:

3.     Speciality clinic/ward:

4.     Hospital and Hospital address/Complete Practice Address: (with postcode)

5.     Telephone Number: (if available)

6.     Email Id: (if available)

Urgency of referral:

    Urgent/Soon/Routine

Patient Details:

    Full name with surname with title (Ms, Mrs., Mr. etc)

Clinical Information:

History of presenting complaint/examination findings/investigation results:

    Details of the presenting complaint: Duration, course and severity of the clinical episode.

    Results of the clinical examination: Eg; Mucocele, Dentoalveolar abscess etc

    Details of the investigations that have been performed: eg Radiographs, OPG etc and provide the copy/original radiographs as enclosement.

Depending on the clinical situation the details needed to be given will vary, but as a general rule, sufficient information should be given to the secondary care giver (to whom we are making the referral) to help make informed judgement about the nature of the problem.

Reason of referral including expected treatment outcome

     Eg: Assessment, investigations and treatment (or) Patient/family request second opinion etc (or) consultation and return to primary care management etc;

    Explicitly state why the referring doctor is making the referral. This will help understand the nature of and reasons for the referral. Indication of the expected referral outcome

    Explicitly state the type of care requested- What we would like the specialist to do!      

Past Medical/Dental History:

    Any specific relevant details that the secondary care giver must know. Eg. Uncontrolled diabetic patient, hypertensive under treatment, failed Root canal therapy etc

Current and Recent Medication:

    Include the current and recent medication along with the 'over the counter' drug being taken by the patient currently.

Clinical warning

Any issue that will put the patient or the health care provider at increased risk (Allergies/hypersensitivities, blood borne viruses)

    The section should include details of the smoking/alcohol/drugs/other abusive habits here with details (eg. packs/number of cigarettes/day etc)

Additional Relevant Information:

• Clinical/social circumstances that might have implication on the treatment planned.

• Special needs related to disability.

• Things the patient might not/cannot divulge to the practioner but which might be important for the practioner to know

• Details of the patients' understanding of their condition.  

        Include explicit details about the expectation of the referral process as expressed by the patient.

P.S:

Any info in red/red and underlined are absolutely essential, Any info in bold or italics is important issue to be considered when referring a patient. Rule of the thumb is that, extra information does no harm, on the other hand missing essential info can have devastating results.

This applies to elective referral letters and NOT TO EMERGENCY REFERRAL ('emergency' refers to life threatening emergencies and must be differentiated from 'urgent conditions' which are NOT life threatening but when left untreated can lead to significant morbidity!) Emergency referrals will have just three-four lines or might even just be limited to phone referral!

An example referral letter format can be as follows: (to a dental specialist)

29 May, 2006

Referring Doctor ( or just 'From')

Dr.