Referral Letter: Structure and Sections
Formal referral letter to another provider or specialist. Notermed's built-in Referral Letter produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Referral Letter contains
5 sections, in the order the note puts them, and what each one takes from the visit.
- 1
RE
- The patient identifier, as stated
- 2
Reason for Referral
- The clinical question or concern prompting the referral
- 3
Clinical Summary
- Presenting complaint
- Relevant history
- Current medications
- Examination findings
- Relevant investigations
- 4
Specific Request
- What the specialist is being asked to do
- Assessment, opinion, management, or procedure
- 5
Urgency
- Routine, semi-urgent, or urgent, when stated
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Referral Letter
What goes into the referral letter?
Five parts: a RE line with the patient identifier as stated, the Reason for Referral, a Clinical Summary, the Specific Request, and Urgency. The clinical summary covers the presenting complaint, relevant history, current medications, examination findings and relevant investigations.
Does the letter say how urgent the referral is?
Only when someone said so. The urgency line records routine, semi-urgent or urgent as it was stated in the visit, and it is left out rather than guessed at when urgency never came up.
What does the specific request say?
What the specialist is being asked to do, in the terms it was asked in: an assessment, an opinion, management, or a procedure. It comes from the visit rather than from a default.
Who signs the referral letter?
The clinician. Notermed drafts the letter from the visit, you edit it, and it stays a draft until you sign it.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Referral Letter on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.