Identifying the problems, solutions, and challenges in referral writing: A Scoping Review

  • Faryal Azhar
  • Tausief Fatima Ameer-ud-Din Medical College LAhore
  • Rehan Ahmed Khan
  • Raheela Yasmin
  • Usman Mehboob
Keywords: Referral letters, Problems, solutions, challenges in implementing referral system, inconsistencies in referral


Abstract Background

Both primary care physicians and other specialists are not satisfied with the quality and content of written communication between colleagues(1).  There is need of identifying the factors that lead to this dissatisfaction. Many of these are discussed in literature such as communication skills, teaching and assessment of referral writings to undergraduates, and lack of validated tool for evaluation of referral(2). This article is scoping review of literature for finding the problems, solutions, and challenges in referral writing.


The databases utilized for finding various referral systems are PubMed, ERIC, Pakmedinet and Google scholar. The article included in the study was 12 which were identified through PRISMA. These 12 articles were reviewed by two authors. (FA and TA) The first step was the application of Qualsyst criteria and then the two authors analyzed the final 12 articles for thematic analysis independently.


The problems, solutions and challenges in referral writing were found after the thematic analysis by two authors. The multiple challenges regarding referral writing include the fact that details about the inadequate data written in referral letters, lack of teaching and learning strategies and lack of proper communication between physicians. There are many solutions like teaching and assessing the referral writing skills, introducing reflection and feedback to improve the skill among young doctors. Moreover, teaching the art of referral writing should include in the medical curriculum.


Referral writing is an important part of medical communication. A good quality referral will save time in management of patients. It will also enhance the outcome of patient management. There is need of teachings about communication skills in undergraduates and postgraduates students.

Author Biography

Tausief Fatima, Ameer-ud-Din Medical College LAhore


Associate Professor surgery,

Ameer-Ud-Din medical college,

Lahore General Hospital, Lahore.


1. NEWTON J, HUTCHINSON A, HAYES V, McCOLL E, MACKEE I, HOLLAND C. Do Clinicians Tell Each Other Enough? An Analysis of Referral Communications in Two Specialties. Fam Pract [Internet]. 1994 Mar 1 [cited 2021 May 20];11(1):15–20. Available from:
2. Vergis A1, Gillman L, Minor S, Taylor M PJ. Structured assessment format for evaluating operative reports in general surgery. Am J Surg. 2008 Jan;195(1):24-9.;
3. Ledwidge M, Barry M, Cahill J, Ryan E, Maurer B, Ryder M, et al. Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care ? 2003;5:381–9.
5. Lingard L (2015). Joining a conversation: the problem Quality of Referrals from Family Medicine to Secondary Care in a University Hospital_. Ramathibodi Med Journa /gap/hook heuristic.
6. Ramanayake RPJC. Structured printed referral letter (form letter); saves time and improves communication. Vol. 2, Journal of Family Medicine and Primary Care. 2013. p. 145.
7. PamelaA. R, JGregory C. Verbal communication skills and patient satisfaction. Eval Heal Prof. 1990;13 no 2.:168–85.
8. Juliani, C., MacPhee, M., & Spiri W (2017). BS. Perspectives on the Patient Referral Process. Heal 5(1), 4 https//
9. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. HTA Initiative. 2004. 1–22 p.
10. Lingard L, Hodges B, Macrae H, Freeman R. Expert and trainee determinations of rhetorical relevance in referral and consultation letters. Med Educ [Internet]. 2004 Feb 1 [cited 2020 Mar 8];38(2):168–76. Available from:
11. Vargas I, Garcia-Subirats I, Mogollón-Pérez AS, Ferreira-De-Medeiros-Mendes M, Eguiguren P, Cisneros AI, et al. Understanding communication breakdown in the outpatient referral process in Latin America: A cross-sectional study on the use of clinical correspondence in public healthcare networks of six countries. Vol. 33, Health Policy and Planning. 2018. p. 494–504.
12. Kathryn A. myers, Erin j. Keely susan D and GRN. myers1999.pdf. Acad Med. 1999;
13. Juliani C, MacPhee M, Spiri W. Brazilian Specialists’ Perspectives on the Patient Referral Process. Healthcare. 2017;5(1):4.
14. Senitan M, Alhaiti AH, Gillespie J. Improving integrated care for chronic non-communicable diseases: A focus on quality referral factors. Int J Healthc Manag. 2019;12(2):106–15.
15. Myers KA, Keely EJ, Dojeiji S, Norman GR. Development of a rating scale to evaluate written communication skills of residents. Acad Med [Internet]. 1999 Oct [cited 2021 May 20];74(10 Suppl):S111-3. Available from:
16. François J. Tool to assess the quality of consultation and referral request letters in family medicine. Vol. 57, Canadian Family Physician. 2011. p. 574–5.
17. Wåhlberg H, Valle PC, Malm S, Broderstad AR. Impact of referral templates on the quality of referrals from primary to secondary care: A cluster randomised trial. Vol. 15, BMC Health Services Research. 2015.
18. Kamau KJ, Osuga BO, Njuguna S. Challenges Facing Implementation Of Referral System For Quality Health Care Services In Kiambu County, Kenya. Heal Syst Policy Res. 2017;04(01):1–8.
19. Newton J, Hutchinson A, Hayes VIC, Mccoll E, Mackee IAN. Do Clinicians Tell Each Other Enough ? An Analysis of Referral Communications in Two Specialties. Fam Pr 1994;11(1)15–20. 1994;11(1):1–6.
20. Give C, Ndima S, Steege R, Ormel H, McCollum R, Theobald S, et al. Strengthening referral systems in community health programs: A qualitative study in two rural districts of Maputo Province, Mozambique. BMC Health Serv Res. 2019;19(1):1–11.
21. Tobin-Schnittger, P., O’Doherty, J., O’Connor, R., & O’Regan A. Improving quality of referral letters from primary to secondary care: A literature review and discussion paper. Prim Healthc Res dev. 2018;
22. Hartveit M, Vanhaecht K, Thorsen O, Biringer E, Haug K, Aslaksen A. Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method. BMC Health Serv Res. 2017;17(1):1–13.
How to Cite
Azhar F, Fatima T, Khan R, Yasmin R, Mehboob U. Identifying the problems, solutions, and challenges in referral writing: A Scoping Review. JRMC [Internet]. 30Jun.2021 [cited 24Sep.2022];25(2):295-00. Available from:
Review Article