What a referral letter must carry

The contents of a referral, the Medicare validity rules, and what a drafted letter supplies for each line.

Written by the aurii team

A referral supporting a specialist attendance must be in writing, and signed and dated by the referring practitioner. A GP referral to a specialist runs for twelve months from the first attendance unless the GP names a different period, and a specialist's referral to another specialist runs for three months.

A general practitioner at a consulting room desk reads a printed letter beside a bright window

Referral contents

A receiving clinic triages on the letter alone, so the question, the history behind it and the result that prompted it belong in the first half page. The Australian Privacy Principles limit disclosure of health information to what is reasonably necessary for the purpose, so a whole record does not belong in a referral.

  • What a referral letter carries, line by line
    What the letter must carryWhat the draft supplies
    Clinical questionOne sentence naming the problem, how long it has run, and the decision being asked of the specialist.Drafted from the recorded consult, in the position the clinician's template sets.
    History of the problemOnset and course, what has been tried, and how the patient responded.Drafted from what was said in the room.
    Background and comorbiditiesConditions and past procedures that change management or triage.Present when they were raised in the consult. The clinician adds what was not.
    Medications and allergiesCurrent medicines with doses, and allergy status.Drafted from the discussion, and checked against the record before signing.
    Examination findingsThe findings that bear on the question being asked.Carried when spoken aloud. An examination done without narration does not reach the draft.
    InvestigationsThe report attached in full, with the single value that prompted the referral quoted in the text.Results enter aurii by upload, with the clinician confirming what was read.
    UrgencyThe timeframe sought, and a phone call to the rooms when the referral is urgent.Set by the clinician at review.
    Access needsInterpreter, mobility or transport needs that shape the appointment.Carried when they were raised in the consult.
    Patient identifiersFull name, date of birth and address, with the Medicare number where the referral supports a claim.Carried from the patient record and confirmed at review.
    RecipientName, practice and provider details, checked against a current directory.Addressed by the clinician before the letter is signed.
    Signature and dateSigned and dated by the referring practitioner.Nothing dispatches from aurii until the letter is signed.

Addressing and follow-up

Check the recipient's name, practice and provider details against a current directory, and copy the patient's usual GP when the referrer is a locum or an after-hours service. Record where the letter went, when, and by what channel, and chase any referral with no acknowledgement.

Delivery

Signed letters go out over Medical Objects. Integrations. Practice systems on the Medical Objects network, including Best Practice, MedicalDirector, Genie, Zedmed and Gentu, are addressable as destinations, and aurii holds no direct integration with any of them.

Review before signing

The check before signing covers identity details, medication names and doses, laterality, dates, allergy status, and whether the clinical question matches what was discussed in the room.

A practice can hold unsigned drafts in a queue separate from sent correspondence.

Nothing leaves aurii until a clinician signs it. Clinical safety.

Referral drafting in aurii

aurii records the consult with the patient's consent and drafts the referral from that recording, in the template set up for that clinician. The draft stays a draft until the treating clinician edits and signs it.

It must be in writing, signed and dated by the referring practitioner, and carry the patient's identifying details. A GP referral to a specialist runs for twelve months from the first attendance unless the GP names a different period, and a specialist's referral to another specialist runs for three months.

aurii drafts the letter from the recorded consult, carrying the question, history, medications and findings that were discussed. It becomes correspondence once the referring clinician has edited and signed it.

Ahpra registration standards leave the practitioner responsible for the content of their records and correspondence, whatever tool produced the draft.

This article is general information about referral letters and documentation workflows. It is not clinical or legal advice.

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