Referral Letter (Sports Medicine/Orthopedics)

From: [Referring clinician name, credentials, practice name]

Phone/Fax: [Best contact for urgent issues]

Date: [Date of letter]

To: [Consultant name if known / Service line (e.g., "Orthopedic Surgery – Sports Medicine")]

Patient: [Full name, DOB, MRN if internal]

Sport/Activity: [Sport, position, level, dominant side] (Omit if not applicable)

Re: Reason for Referral

[Right / Left / Bilateral / Laterality unclear] [Body region] [Primary condition/concern] ([Routine / Urgent / Stat][—brief justification if urgent or stat])

Clinical Summary

[1–3 sentence executive summary including mechanism/onset, duration, key exam finding, working diagnosis or concern, and specific action requested of the consultant] (Write so this paragraph can stand alone.)

History & Treatment

• Mechanism & timing: [Traumatic / Atraumatic]; [contact / noncontact]; [event description]; [onset date]; [acute / subacute / chronic]
• Symptoms & function: [Location; quality (pain, instability, locking, swelling, weakness); severity; aggravating/relieving factors; impact on sport/work/ADLs]
• Red flags screened: [Fever, night pain, neurologic deficits, systemic symptoms] [Present—specify / Absent / Not assessed]
• Treatments tried: [Activity modification, medications (name, dose, duration), PT/rehab (type, duration, adherence), bracing, injections/procedures—for each, state response: helped / no effect / worsened / not tried]
• Prior injury/surgery (same region): [Details / None / Unknown]
• Procedural considerations: [Anticoagulants, antiplatelets, relevant allergies (NSAIDs, contrast, local anesthetics)] [Verified / Unknown]

(Use "Not tried," "Unknown," or "Not obtained" rather than leaving blank. Omit full ROS unless directly relevant.)

Pertinent Findings

• Exam: [Inspection; tenderness; ROM (degrees if limited); strength; provocative/special tests with positives and key negatives; neurovascular status; gait/functional assessment] (If exam not performed, state why.)
• Imaging/Labs: [Modality, body part, laterality, date, key findings] [No imaging to date / Pending—study and expected timeline]

Assessment & Request

[Working diagnosis or differential using "Concern for" / "Suspected" / "Rule out" with brief supporting rationale]

1. [Specific question or request for consultant]
2. [Additional question if applicable]

(If red flags or limb-threatening findings are present, document that direct clinician-to-clinician communication or ED referral was initiated.)

Closing

Attachments: [Imaging reports, clinic notes, operative reports, forms / None]

Patient informed: [Patient informed of and agrees with referral / Not discussed]

Sincerely,

[Clinician name, credentials]
[Direct contact for urgent clarification]