GP referral and discharge letters: what a good one contains and how to write them clearly

What a GP needs from your letter

A GP may read dozens of letters in a sitting. They are looking for three things, in this order: what you found, what you did or recommend, and what you need them to do. Everything else is supporting detail.

A referral letter asks for something: an investigation, a prescription review, a specialist referral, or simply awareness. A discharge letter closes a loop: it says what was done, how the patient is now, and what happens next. Both fail when the request or the outcome is buried in a paragraph of history.

• The ask, up front. One sentence at the top: why you are writing and what you would like the GP to do.
• Enough history to make sense of it. The presenting problem, relevant findings, and what you have already tried. Not the whole file.
• Clear ownership. Who is doing what next, and by when, if timing matters.
• Your contact details. A GP with a question should not have to hunt for how to reach you.

A structure that works

Most good letters follow the same shape, whatever the profession. Keep each part short and put the important thing first.

Referral letters

• Reason for writing and the specific request.
• Presenting problem and duration, in the patient’s terms where useful.
• Relevant findings, including negative findings that change the picture.
• What you have done so far and the response.
• Current medications and allergies only as the patient reports them, flagged as such, unless you have verified them.
• Urgency, and why, if it is not routine.

Discharge letters

• Reason the patient attended and the dates of care.
• What was assessed and treated, and how the patient is now.
• What the patient has been advised to do and what to watch for.
• Any follow-up you have arranged and any you are asking the GP to consider.
• Whether the patient may return and how.

Plain language beats jargon, but use the terms your colleague would use. Avoid abbreviations that are local to your clinic, and avoid long lists of everything you tested when only two results matter.

Consent, privacy and who may see the letter

Before a letter leaves the clinic, check that the patient knows it is being sent and to whom. Many clinics ask at the first visit who the patient’s regular GP is, record whether the patient agrees to correspondence being sent, and confirm again if the letter covers something sensitive.

• Confirm the patient’s agreement to share information with this GP, and record that you did.
• Share what is relevant to the purpose of the letter, not everything in the record.
• Check you have the right GP and the right address or secure channel before sending.
• Be careful with sensitive information, third-party information and anything the patient has asked you to keep out.

What the privacy law and your professional standards require of you, and in what circumstances, depends on your profession and your state or territory. Check with your professional body, your insurer or the relevant authority. This guide is general information, not legal advice.

Review and sign-off: the clinician decides

A letter is a clinical document under your name. Whoever or whatever produced the first draft, a clinician should read every word before it is sent, check it against the record, and take responsibility for it.

A practical review checklist:

• Is the patient correct, with the right date of birth and the right GP?
• Does the opening sentence say what you want the GP to do or know?
• Are findings, diagnoses and medications stated as they are in the record, with nothing added?
• Is anything in the letter something you did not assess or do?
• Is anything missing that the GP will need to act?
• Is the tone right for this patient and this colleague?

Pay particular attention to anything that reads smoothly but that you did not write. A fluent sentence is not necessarily a correct one.

Where drafting tools help, and where they stop

Writing a letter from scratch means re-reading the visit note, pulling out the relevant points and typing them in a form the GP will find useful. Much of that is assembly, and assembly is where a tool can help.

• Good for: pulling together demographics, dates of care and the GP’s details; producing a first-pass structure from the visit record; keeping your clinic’s letter format consistent.
• Not for: deciding what is clinically relevant to this GP, whether to refer, how urgent it is, or what to say about a difficult finding. Those are clinical judgements and stay with the clinician.

Praxia can draft a first-pass referral or discharge letter to a GP, and a clinician reviews and approves every draft before anything is sent. The draft is a starting point. Nothing goes out until a clinician has approved it.

Each clinic’s data is kept isolated from every other clinic’s. Some services we rely on are overseas, and we disclose each in our privacy policy. If where a letter is drafted matters to your clinic’s privacy position, ask us for the details at a walkthrough.

Access in Praxia is role based, and we keep an audit trail of key actions. Whichever tool you use, make sure you can tell who approved a letter and when.

Common errors in GP letters

• Burying the ask. The request appears in the fourth paragraph, or not at all.
• Too much detail. The GP has to find the two relevant findings in a page of results.
• Copy-forward mistakes. Text carried over from an earlier letter or another patient, including names and pronouns.
• Wrong recipient. Sent to a previous GP, or to a practice the patient has left.
• Unverified medications. Listed as current when they are only what the patient said at one visit.
• Unclear ownership. Both the clinic and the GP think the other is arranging the follow-up.
• Late discharge letters. Sent weeks after the last visit, when the GP has already seen the patient.
• Unreviewed drafts. Sent with the draft’s placeholder text or an unchecked statement still in it.

A reusable outline

Copy this into your own template and adjust it to your profession and your clinic’s standards.

To: [GP name, practice]
Re: [Patient name, date of birth]
Date: [date]

Reason for writing:
[One sentence: what you are asking or reporting.]

Background:
[Presenting problem, duration, relevant history.]

Findings:
[Relevant positives and negatives.]

Care provided and response:
[What you did, over what dates, and the result.]

Current status:
[How the patient is now.]

Request or recommendation:
[What you would like the GP to do, and any timing.]

Follow-up arranged:
[Who is doing what next.]

Patient informed and agreed to this letter: [yes, date]

[Clinician name, profession, registration number, contact details]

Keep one outline for referrals and one for discharge, and let each clinician edit the wording to sound like themselves. Review your outlines every so often with a GP or two who receive your letters regularly, and ask what they would drop and what they would add.

Questions clinics ask

Where Praxia fits, and where this guide stops

Praxia is a pilot with Evolution Medical Care, a clinic run by Praxia’s founders, and is being onboarded to it now. Praxia Clinical Solutions is an Australian company, currently in incorporation. Pricing is published on our pricing page, from A$199 per practitioner per month for a solo clinic, stepping down as a clinic grows, in Australian dollars and excluding GST. There is a 30 day free trial that starts once a person from Praxia has completed your onboarding (the guided set-up session and the load check), nothing is charged during the trial, and no card is needed to start. If you agree, the next 5 months are invoiced month by month at half the list price for your clinic size, and the list price applies after that. Paid months are opt-in: we tell you in writing, with the amount, at least 7 days before the trial ends, and nothing is charged unless you agree in writing. We do not promise free migration.

This guide is general information from how clinics work and from what Praxia is built to do. It is not legal, clinical or financial advice, and nothing here promises a result for your clinic.

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