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Give the receiving service the clinical context, relevant findings, and requested action in a concise handover.
Structure
Adapt headings to local policy, specialty, encounter type, and record requirements.
State the problem, purpose of referral, suspected diagnosis or question, and why input is needed now.
Include the history, findings, results, medicines, allergies, prior management, risk, and functional or social context relevant to the request.
Specify the action requested, urgency, responsible service, pending work, and what should happen if the condition changes while waiting.
Document-specific checks
Check patient and recipient identifiers, referral destination, reason, urgency, and whether the receiving service can triage from the opening section.
Remove unrelated detail while preserving red flags, relevant negatives, investigations, treatment response, comorbidity, medicines, and accessibility needs.
Confirm ownership of interim care, pending results, patient information, safety-netting, attachments, and the route for clarification or rejection.
Review
Remove unsupported detail and confirm that attribution, chronology, negatives, and uncertainty match the encounter.
Verify medicines, doses, measurements, diagnoses, risk statements, investigations, and follow-up instructions.
Make the requested action, owner, urgency, and handover information unambiguous where they apply.
Workflow
Select the template that matches the documentation purpose before generating the draft.
Use encounter content to populate the structure, then correct omissions, wording, and section placement.
Only move the document into its destination after the responsible clinician has completed the review.
Continue exploring
These pages add the operational, documentation, and trust context around this topic.
Next step
Generate a structured draft, then verify every material detail before it becomes part of the clinical record.