How to write a referral to a dermatologist

Created 2008.

Learning objectives

• Complete a referral form according to the requirements of the New Zealand Ministry of Health.
• Write a dermatological case history
• Describe dermatological examination findings

Introduction

A patient presents with a skin complaint. You decide to refer the patient to a dermatologist for further management. In this exercise, you will complete a standardised referral form to the local hospital's skin clinic.

Referral form

The New Zealand Ministry of Health requires standard referral forms to have the following minimal information.

• Patient details: full name (and any alias) and if appropriate the name of the parent or caregiver, address, telephone number (home and alternative), date of birth, ethnicity
• GP details: name, address, telephone number of referred doctor
• Patient hospital number (NHI)
• Accident status and claim number (if ACC)
• Reason for referral (in line with referral guidelines)
• Presenting symptoms and duration
• Past history, details of previous treatment, current, medications
• Details of previous radiological and other investigations
• Physical findings
• Recent test results and relevant old ones (dated)
• Associated medical conditions that may affect treatment
• Relevant details of social circumstances
• Associated drug allergies
• GP diagnosis
• GP assessment of urgency, loss of function, pain

Activity

Write a referral for a woman in her mid-20s that suffers from moderate psoriasis. She is severely depressed and takes various relevant medications.