This first step is perhaps the most important when preparing to make a referral. Your registrar or resident will tell you which patient you will be making a referral for, and to whom. Depending on the type of referral you will be making, this person will usually be the receiving registrar of a medical or surgical team, or a radiology registrar or consultant.
The two essential details you will also need to know include: why the referral is being made, and what clinical question is being asked. By clinical question, we mean what you specifically want to find out or request from the doctor you’re referring to.
If unsure of either of these details, clarify these first with your team before moving ahead!
The referral process differs between and even within hospital systems. You might find some units request to be paged first so they can call you back, whilst others prefer for you to directly call the receiving registrar’s mobile phone.
Ask your registrar or resident if they know how the unit you’ll be referring to is typically contacted. Otherwise if they’re unsure, call the hospital switchboard and they should point you in the right direction. Try to also get the name of the doctor in advance so you know who you’re speaking to. Note that they also may be a consultant or registrar depending on the unit, time of referral and rostering.
Each specialty will want to know different details about your patient and their presenting complaint. For example, if referring a diabetic patient to endocrinology, they will want to know the patient’s recent blood sugar levels, HbA1c, anti-glycaemic treatments, and current nutritional status.
Go Through the Patient Records
Familiarise yourself with your patient’s clinical history and management thus far. Next, check the patient’s up-to-date vital signs, as well as any recent bloods or imaging results.
The amount of information available will depend on how long the patient has been in hospital. Especially if you’re referring from ED, there won’t be much previous information available unless the patient has had a recent admission or attends outpatient clinics at your hospital. In this case, you’ll mainly need to work off the patient’s current presentation, clinical findings and your differentials.
If you’re referring an inpatient, read through the patient’s admission and recent progress notes and note down details relevant to the referral you’ll be making. It’s also useful to look out for any previous notes made by the team you’ll be referring to. If they’re already familiar with your patient, this will make the referral a whole lot easier!
ISBAR is a widely used framework you can use to help structure your referral. Depending on how confident or experienced you are with making referrals, you may also want to jot down the salient points on your patient in advance following the ISBAR structure.
Introduction - identify yourself, identify who you’re speaking to, identify the patient
Situation - state your reason for calling and if it’s urgent
Background - relevant history, examination, investigations and management to date
Assessment - state what you think is going on
Recommendation / Request - state your request (some prefer you actually state this earlier in the call so as to direct the person you’re calling to the main issue from the outset)
Here’s an example of how you can set it out:
I - Mrs Karen Lee 70F, UR 123456, brought in by ambulance 10 minutes ago
S - sudden central radiating chest pain, new ST elevation on ECG leads V1-V3, urgent
B - poorly controlled hypertension, high cholesterol, heavy smoker, appears pale but is haemodynamically stable, ECG/troponins/baseline bloods ordered, has been given aspirin, GTN and morphine
A - anterior STEMI
R - urgent cardio review for ?PCI
Practice Your One Sentence Summary
Following your initial introduction, all good referrals should begin with a succinct one sentence summary of why you’re calling. This sentence should link your reason for calling with the patient’s current situation, as well as highlight the urgency of the referral.
As this single sentence is very important in framing your referral, it can be good to rehearse it beforehand, whether this be in your head or out loud. If your registrar or resident is free, ask if they can listen to your one sentence summary and provide feedback before you make the actual phone call.
During the Referral
Just like making any phone call to someone you don’t know, ensure you introduce yourself at the beginning of the call.
Bonus tip: Let the person taking the call know you’re a medical student. The vast majority of doctors who take referrals are very receptive over the phone, however, chances are they will be more lenient - and if you’re lucky even provide valuable feedback and/or teaching - if you indicate that you’re still on your L plates.
Doctors are in general also very busy, so don’t forget to follow referral etiquette and check whether it’s convenient to talk now or to call back later.
Here’s an example of how you can open the call:
“Hi, my name is ____, the medical student from the ____ team. I’m calling to refer one of our patients for your opinion on ____. Is now a good time to talk?”
Don’t forget the UR number
If you’re fortunate to be at a hospital that uses electronic medical records, include the patient’s identifying UR number so the person receiving your call can look up patient information during or after your referral. This is particularly helpful for them if the patient is complex or your initial referral is missing some extra detail.
Prepare yourself for questions
It’s completely normal for the person taking your referral to ask a few, if not multiple questions throughout the phone call. This enables them to gather the necessary clinical information to address your request.
On the same note, ensure that you leave some gaps while you speak so the other person can have opportunities to jump in and ask questions if they need to.
As you may not necessarily know the answers to these targeted questions, keep your patient’s records open so you can quickly refer to them as required.
Ending the call
At the end of the call, repeat back the plan or any of the suggestions provided to ensure there has been no miscommunication. Writing this all down on paper is also recommended.
Taking and following up on a new referral can occupy a considerable amount of time for a doctor, so it’s important to thank the person on the other end when concluding your call. After all, hospitals are small places so there’s a high likelihood you’ll be remembered if you cross paths again! You want to leave a good impression.
After the referral
Document the phone call in the patient records. Note down who you spoke to, the reason for referring, what was discussed in the conversation, and a clear outline of planned steps to be taken.
It’s also common courtesy to begin with a brief note of thanks to the doctor who took on your referral, for example:
“Phone consult regarding [patient’s] [issue] from Dr ____, with thanks”.
It is important to be as concise and thorough as possible in your documentation, because this not only serves as a point of referral for your own unit, but also for other interdisciplinary teams involved in your patient’s care. Written medical records are also legal documents, so for the protection of yourself and your patient, it’s vital that you document properly in the chance your notes are scrutinised in legal proceedings later on.
Follow-up with your team
Ensure closed loop communication by letting your registrar or resident know that you’ve completed your referral.
Handover the outcome of the phone call, as well as any outstanding tasks that have been requested for your team to follow up on. This can include further investigations such as bloods or imaging, and changes to treatment plan. If you’re able to, offer to help carry out these tasks too.
Follow-up with your patient
Having now familiarised yourself with your patient, take the opportunity to further your learning by following them throughout the rest of their admission. By keeping yourself up to date with their clinical progress, you’ll be able to gain a broad picture of issues and practice points to look out for when managing similar patients in the future. Writing up a case report on your patient is also a great way to consolidate on what you’ve observed for your studies.
Reflect, Revise, Ready
Finally, remember there is no such thing as the perfect referral!
If you have received feedback on your referral from your team or the doctor who you made the referral to, reflect and revise on this so you can improve the next time. You’ll also find that with each referral you take on, the process will gradually feel less nerve racking and more natural.