Always write the Date, and in emergency cases, the time to document when you have referred.
You may not write detailed examination findings but you clinical impression and the reason for which you are referring should be clear form your letter
If any investigations, x-ray scans, etc. have been done, instruct the patient to carry the reports with them
Always inform what treatment you have given as emergency treatment or in the past, egg. After an injury, is Inj. T.T. given? In fever, what antibiotic you have tried & found ineffective, in Gastroenteritis, how much I.V. fluids have been given etc.
If patient is allergic to any drug, the information must be conveyed to avoid unwanted reactions. Allergy known about one drug will make the doctor alert while giving other drugs also.
Many times a patient may be suffering from chronic diseases like Diabetes, Asthma, Hypertension etc. the treatment being taken for such conditions should be mentioned.
