AtlacareWhen a patient arrives with a GP or NHS referral, the letter is part of their clinical record — it sets the reason for treatment and, for insured or medico-legal work, it's often required evidence. Keep it on the record rather than in an inbox.
Record the referral
- Add the patient (or open their record if they exist).
- Attach the letter to their file — scan or save the PDF and upload it, so the original is stored securely in the EU alongside the rest of their record. See attaching files to a patient.
- Note the context in the first clinical note or the conversation log: who referred, the date, and the presenting reason. That way the referral reason is searchable, not just buried in a PDF.
Why it matters
- Clinical — the referral frames the assessment and the plan.
- Insurance — many insurers require a GP referral before they'll authorise treatment; having it on file supports the claim. Pair it with the insurance authorisation.
- Medico-legal — if the episode is ever reviewed, the referral is part of the story of care.
Referring back or onward
If you need to write back to the GP or refer the patient on, keep a copy of your letter on the patient's file too, so both sides of the correspondence are recorded.
Treat the referral like any other clinical document: stored on the record, retained for the same period, and included if the patient makes a subject access request.