Referral Letter Template and Referral Tracking Log
The five things a referral must contain, and the log that catches the patient who never arrived
What it is
A one-page referral letter with the five essentials (reason and question, relevant history and findings, current medicines and allergies, urgency, what the patient has been told) and a tracking log to confirm the referral was received, the patient was seen, and the reply came back.
Where to use it
Every clinician; the log kept by reception and reviewed weekly. Evidence for: Ambulatory Standard 6 — referral and continuity; Standard 2 — communication. Evidence for: Ambulatory Standard 6 — referral and continuity; Standard 2 — communication. Evidence for: Ambulatory Standard 6 — referral and continuity; Standard 2 — communication. Evidence for: Ambulatory Standard 6 — referral and continuity; Standard 2 — communication.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Same-Day Access and Triage — Reception Protocol
Minor Procedure Safety Checklist — Clinic and Dental
Dental Infection Control — Instrument Reprocessing and Waterline Checklist
Clinic Emergency Box — Contents and Monthly Check
Consent for a Clinic or Dental Procedure — Form and Record
Print to share.
