What Makes a Good Surgical Referral?

A high-quality surgical referral letter is like handing a surgeon a clear roadmap—it helps your patient get the right care without unnecessary delays. As an orthopaedic surgeon, I’ve seen how much more efficient and effective surgery planning becomes when GP colleagues provide detailed, well-structured referrals. Here’s how to make yours shine:

1. Clear Clinical Summary

Start with a focused patient overview:

• What’s the story? When did symptoms start, and how have they progressed?
• What’s affecting them most? Paint a picture of pain, stiffness, weakness or dysfunction.
• Medical backdrop: List relevant past surgeries, chronic conditions, and medication including allergies.

Why it helps: A concise summary sets priorities for investigation and surgical planning.

2. Attach High-Quality Imaging

For musculoskeletal issues, modern imaging is vital. Include:

• X‑rays (AP/lateral) – weight‑bearing if relevant (knees, ankles, hips).
• MRI/CT scans – for soft‑tissue or bony detail.
• Latest imaging only, with visible dates.
• Attach DICOMs or clear labelled JPEGs/PDFs—not just handwritten notes or summaries.

Why it helps: Seeing the anatomy firsthand speeds decision-making and reduces duplication.

3. Key Clinical Details to Include

Detail is your friend. Here’s what I need to know:

A. Examination Findings

• Range of motion (e.g., “Left knee ROM 0–110°”), any instability or deformity?
• Physical exam findings (e.g., “Medial joint line tenderness, positive Lachman test”).

B. Functional Impact

• How is daily life affected? (Walking, stairs, dressing, sports, work)
• Any assistive devices used?

C. Non-Surgical Trial Summary

• Treatments tried so far (medications, physio, injections, braces)
• Duration and patient response

D. Specific Clinical Questions

• What is the GP hoping for? (e.g., “Consider surgical repair of rotator cuff if symptomatic in 6 months.”)
• Any expectations or preferences (e.g., minimal hospital stay, preserving joint space)?

4. Referral Clarity and Priority

• Reason for referral: Surgery planning? Second opinion? Urgent review?
• Time sensitivity: Label as routine, semi-urgent (e.g., 4–6 weeks), or urgent (e.g., red flags of tumour/infection).
• Preferred surgeon or location if patient has a preference.

5. Logistics & Administrative Essentials

• Include patient demographics: name, DOB, Medicare/VIC MHCP/referral validity.
• Ensure legible contact details for both GP and patient.
• If relevant, note private insurance status or Medicare reports are enclosed.

6. Don’t Overlook the Soft Stuff

A snapshot of patient goals and lifestyle greatly enriches surgical planning:

• Does this patient want to return to beach volleyball? Keep driving independently?
• Highlight patient motivation and engagement with non‑surgical treatments.

Example Referral Letter (Short Form)

"Mr John Smith (DOB: 1 Jan 1965) presents with 12 months of progressive right knee pain, worse on stairs and walking >500m. Exam: ROM 5–110°, medial joint line tenderness, no varus/valgus laxity. BMI 29, history of hypertension. Conservative management: 8 sessions physio (partial relief), NSAIDs PRN, unsuccessful corticosteroid injection in Jan '25.

Recent standing AP/lateral right knee X‑rays by Central Radiology (dated 3 Jun ‘25) are attached. Impression: moderate medial compartment osteoarthritis with joint space narrowing (4 mm).

Patient reports reduced work capacity (tradesman by profession) and inability to play golf—keen on returning to work and sport. He is motivated, covered by private health and would like possible knee replacement evaluation.

Referral: Semi‑urgent assessment for possible total knee replacement.

Please contact via MyHealthLink for urgent appointments."

Collaboration is Key

A well-crafted referral benefits everyone:

• GPs: patients feel heard and supported.
• Surgeons: better information leads to faster, safer decisions.
• Patients: shorter wait times, less repetition, clearer care journey.

And in my years as an orthopaedic surgeon, it’s precisely this level of teamwork that leads to better outcomes.

Frequently Asked Questions (FAQ)

1. Should I include all past imaging?

Only recent relevant imaging (usually within a year) is needed. Older studies can be described or retrieved later if useful.

2. What if imaging isn’t done yet?

You can request “Imaging requested prior to surgical review” to avoid unnecessary re-imaging post-referral.

3. GP wants urgent review — what are red flags?

Signs like night sweats, unexplained weight loss, rapid onset, systemic illness or history of cancer should be labelled urgent and flagged clearly.

4. Do I need to stage treatments (e.g., physio first)?

Yes—even if limited response—mentioning trials shows you’ve explored non-operative care, essential for surgical assessment.

5. How long is a referral valid?

Medicare referrals last 12 months from issue for specialist consultations. For surgical cases, sooner is better.

Closing Thoughts

Referral letters are more than paperwork—they’re the first chapter of a patient’s surgical journey. A structured, detailed referral speeds up care, reduces diagnostic waste, and supports clear surgical planning. It’s a small task that can make a big difference.