Doctor Referral Forms

In medical practice, it is quite common that patients are shifted from one medical facility to another. This especially depends upon the nature of the health facility and the level of the expertise of the doctor.

When does a patient need to be referred?

For example, a midwife sitting in a far off remote area of the country when encounters a laboring patient with full-blown eclampsia, she definitely needs to refer this patient to tertiary care hospital for better management and delivery of the baby.

Similarly, if a junior doctor faces a severe road traffic accident in the local dispensary, he needs to refer such patient to tertiary care after providing the first aid.

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So, referring a patient from one place to another is a common practice and all the time doctors are exchanging patients so that the right healthy facility comes in the approach of the patient.

How is a patient referred?

There is a proper method for every action taken in medical sciences even in cases of emergencies. One has to follow proper protocol while referring a patient from one place to another. We can’t just verbally say to the attendants about the critical condition of the patient and cannot advise just verbally to take them to some better health facility.

You have to make a proper referral form and mention all the current situation and advice and sign it properly. Good health care facilities also provide an ambulance to transfer the patient out.

Doctor referral form

  1. The first and foremost thing in a referral form is the complete name of the doctor, his contact number and address. It is really important because we want to send the patient to the right doctor in the safest possible span of time.
  2. The date is also mentioned with time to show when the patient was attended and how much time was spent in the primary health care center to get the idea of delay or prompt management. This is critical in case of management of emergencies. Every second counts literally.
  3. Then we have to mention the information about the patient. Name of the patient, his medical record number, his age, sex, and contact number is written in the beginning.
  4. Then we mention details about the patient’s complaints when he reached the first doctor. His presenting complaints and his past medical and surgical history is mentioned. If there is anything significant in his allergy, drug, transfusion history that is also mentioned in the form to give a whole lot of information.
  5. Examination done at the time of admission is also important also any treatment provided.
  6. Differential diagnosis or final diagnosis if made is written at the end and also we mention the reason why we are referring this patient to another doctor. Emergency or no emergency, we have to write the reason for referral to another doctor.
  7. In the end, the doctor who is referring the patient can write his comments if any. Especially treatment given at his place and his vitals and general condition after the treatment was given.

See the samples below prepared by the relevant sources.

Doctor referral form
Source: https://www.ucsfhealth.org/
Doctor referral form
Source: https://stanfordhealthcare.org/
Doctor referral form
Source: https://www.ucsfbenioffchildrens.org/

Simi Karton

Dr. Simi Karton is a regular contributor to National Science Quarterly and an enthusiastic Lakers fan. She recently collaborated on a manuscript with friends and colleagues. Dr. Simi Karton, entitled Parkinsons and the Genetic Response to Eastern Medicine, in which she and Dr. Inshal presented research compiled during a summer spent in United States. She currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health related information stuff at an easy approach. The information has been collected from different sources at one place.

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