Referral Letter (Pediatrics)

Date: [date of letter]
To: [receiving clinician name, specialty/clinic, facility]
From: [referring clinician name, credentials, practice, phone]
Patient: [full name], DOB [date], MRN [if available]
Parent/Guardian: [name(s) and relationship; note consent authority if relevant]
Preferred Language: [language; interpreter needed: [yes / no]]
Contact: [best phone number and safe voicemail instructions if known]

(Use clear, family-friendly language. Define uncommon abbreviations on first mention. Include only information pertinent to the consult question and triage. Date-stamp clinically meaningful events. Omit entire sections if not relevant, except Medications and Allergies must always include an explicit statement.)

Referral Summary

[Patient age] [one-line clinical synopsis orienting the consultant]. Urgency: [routine / urgent / emergent]. (If not routine, briefly state rationale.) Current status: [outpatient / ED / hospitalized]. (Limit to 1–3 sentences; lead with age. For complex patients, include a brief medical complexity descriptor.)

Consult Question

[Explicit clinical question(s)] (State the expected role: [one-time evaluation / comanagement / assumption of care / procedure]. Include specific requests such as imaging guidance, medication recommendations, or clearance needs. Note relevant scheduling limitations or family preferences. Use a brief bulleted list only if multiple discrete questions; otherwise use paragraph format.)

Clinical Background

[History of present illness including onset, course, severity, pertinent positives and negatives, baseline function, and impact on daily activities] (For pediatrics, include relevant birth history, developmental milestones, growth concerns, or immunization status when pertinent to the consult question. Integrate prior evaluations and outcomes and any directly relevant family history. If information is unavailable, state explicitly, e.g., "Birth history not available.")

Medications: [current medications with dose, frequency, and indication] (If none, state "No current medications.")

Allergies: [substance, reaction type, severity] (If none, state "No known drug allergies.")

Pertinent Findings

Vitals/Growth: [weight, height/length, BMI percentile, head circumference for infants, with date]

Exam: [pertinent positives and negatives relevant to the consult question] (Do not include a complete normal exam.)

Key Results: [laboratory, imaging, or screening results with date and brief interpretation] (Note any pending tests with expected timing. If attaching full reports, still include key takeaways here.)

Assessment & Management to Date

[Working impression with appropriate qualification, e.g., "most consistent with...", "cannot exclude..."; include main differential considerations relevant to triage] (Summarize treatments tried and response, and what the family has been told about next steps and safety-net guidance. Note any direct clinician-to-clinician communication if referral is urgent.)

[Family concerns, functional impacts, and social or logistical considerations the consultant should know] (Include school, sports, sleep impacts; transportation or scheduling constraints; medication formulation preferences. For adolescents, note if any history was obtained confidentially and handle per confidentiality policy. If safety concerns or consent/guardianship complexities exist, include brief factual statement.)

[Clinician name, credentials]
[Practice/clinic name]
[Direct contact information]
cc: [distribution list if applicable]