Student Referral Letter (Specialty Consultation)

Header

Date/Time: [date and time sent]
Consult Type: [formal referral request / advice-curbside question / e-consult]
To: [specialty and consultant name if known]
Patient: [name, DOB, MRN per institutional policy]
Location: [outpatient / ED / inpatient unit; note if currently admitted]
Urgency: [routine / urgent with timeframe / emergent]
From: [student name, program, service]
Supervisor: [attending or resident name and callback number]
Callback: [preferred contact method and availability]

(If any routing element is unknown, state "unknown" explicitly rather than leaving blank.)

Consult Question

[One-sentence patient summary: age, relevant sex/gender if clinically pertinent, key problem, and current status]

1. [Specific, answerable question tied to an immediate decision point]
2. [Second focused question, if needed]
3. [Third question, if needed]

(Lead with the decision point. Prefer management-focused questions over vague requests to "evaluate." Omit unused question slots.)

Background

[Onset, duration, course, severity, and key associated symptoms; pertinent negatives that change risk]

[Pertinent past medical and surgical history affecting risk or treatment options]

[Relevant medications with dose and start date when clinically important; medication reconciliation status if incomplete]

[Allergy status: NKDA / specific allergy with reaction type / allergies not yet verified]

[Pertinent social or exposure history if it changes likelihood or management]

(Include only details supporting the consult questions. Use "denies" for explicitly asked negatives, "not assessed" if not asked, "unknown" if unobtainable.)

Current Status

• [Vitals or stability statement with date/time]
• [Pertinent exam findings tied to the consult question]
• [Relevant lab/imaging results with headline abnormals and dates; note pending studies]

(If exam not performed, state "exam not performed (chart review only)." Omit normal results unless pertinent.)

Management & Request

[Treatments attempted to date with doses, durations, and patient response]

[Interventions already planned or ordered]

[Explicit request aligned to numbered questions: type of guidance sought, advice-only vs transfer of care, safety net or escalation plan while awaiting response]

Signature

Student: [student name, role, service]
Supervising Clinician: [name and contact]
[Attestation statement per local policy, e.g., "Discussed with [supervising clinician name]"]