Referral Letter/Consult Summary (To Referring Provider)

Date: [letter date]
To: [referring clinician name, credentials, clinic]
Re: [patient full name], DOB [date of birth]
Encounter Date: [date of evaluation]

(Include salutation only if the receiving system does not auto-insert one.) Dear Dr. [referring clinician last name], thank you for referring [patient name] for evaluation of [referral question].

Reason for Consultation

[Referral question and scope of consultation] (State the specific question in 1–3 sentences. If relevant, state scope: [opinion only / assume management / shared care].)

Summary & Assessment

(Lead with the answer. Keep scannable; avoid routine or non-decision-making details.)

• Primary diagnosis/impression: [diagnosis with laterality and severity as applicable] (Note if working diagnosis vs confirmed, only if this impacts next steps.)
• Key supporting findings: [2–6 pertinent exam findings, critical test results, or clinical observations that directly support the impression]
• Today: [treatments started/stopped, procedures performed, counseling provided] (Include doses, route, and frequency for any medications initiated or changed.)
• Pertinent history: [brief HPI and relevant PMH/meds/allergies that materially inform recommendations] (Omit routine negatives. State "Allergies: unknown" if not documented.)

Recommendations & Plan

(Organize by problem if multiple issues. Use bold to highlight action items and time-sensitive requests.)

[Problem]: [diagnosis/issue]

• Treatment: [specific medication(s) with dose, route, frequency, duration] [adjuncts/non-pharmacologic measures as applicable]
• Monitoring: [what to monitor, target/thresholds, timeframe]
• Responsibilities: [Consultant will: specific tasks] [Referring clinician please: specific tasks] (Explicitly delineate who does what.)
• Escalation: [If metric/symptom exceeds threshold after timeframe, action to take] (Include concrete if/then guidance.)

(Repeat problem section as needed for multi-issue consults. Omit if single-issue.)

Co-management / Transfer of Care

(Include only if postoperative co-management or transfer of care applies.)

• Care model: [shared care / full transfer to consultant / return to PCP after stabilization]
• Transfer date: [exact date care transfers, if applicable]
• Clinical stability: [stable / unstable] — [brief rationale]
• Patient informed and consented: [yes / no]

Follow-Up & Contact

• Next appointment: [timeframe] with [clinician/service]
• Return precautions: [symptom-based red flags with time windows for action]
• Pending results: [test(s) pending] — [who will follow up and how results will be communicated] (Omit if none pending.)
• Direct clinician contact: [phone/pager/secure message for urgent questions]

(Omit any sections or bullets that do not add decision-making value.)

Sincerely,

[Consulting clinician name], [credentials]
[Specialty]
[Clinic/Institution]
[Callback phone]