Example of a Full Format Reference Letter

A referral letter is a formal introductory letter from a medical professional (such as a general practitioner or dentist) addressed to another doctor or dentist. Its purpose is to provide advice (treatment instructions) or to refer the patient for further treatment to a specialist with greater expertise in that specific field. In dentistry, for example, if a general dentist suspects a tumor, the patient should be referred to a more competent specialist, such as an oral pathologist. Similarly, a dentist may refer a patient to a general practitioner or an internist to assess the patient’s blood sugar and blood pressure levels.

Indonesia’s national health insurance system, BPJS Kesehatan, employs a tiered referral system. Patients must first seek treatment at primary healthcare facilities (Faskes 1: Puskesmas or Clinics). If the condition cannot be managed at this level, the primary facility will provide a referral to a secondary or tertiary facility (Hospital).

A referral letter is issued by a clinic or public health center (Puskesmas) as a form of transferring responsibility for a medical issue. There are two types of referrals: medical referrals and health referrals.

BPJS Kesehatan referral letters fall under the category of medical referrals (patient referrals). Referral letters issued from a primary facility to a hospital have an expiration date. How long is a BPJS referral valid? It is valid for a maximum of 1 month (30 days), provided it is not for a new case.

If the health case is different, you may request a new referral for the specific condition being treated. Referrals are issued based on medical indications; when patients go to the hospital with a valid referral, BPJS Kesehatan will provide health coverage according to their entitlements.

Please note that emergency conditions do not require a referral. Patients or their families can go directly to the Emergency Room (IGD/ER) for immediate and appropriate care.

Creating a Referral Letter

A referral is an effort to delegate the authority and responsibility for managing a patient’s condition to another appropriate doctor. Below are the procedures for referrals:

Referral Procedures:

1. Limited only to the specific disease problem being referred.

2. Maintaining communication between the consultant doctor and the requesting doctor.

3. Agreement on the division of authority and responsibility of each party.

Division of Authority and Responsibility:

1. Interval referral: Complete transfer of authority and responsibility to the consultant doctor for a certain period, during which the original doctor does not treat the patient.

2. Collateral referral: Transfer of authority and responsibility for one specific medical problem only.

3. Cross referral: Permanent transfer of authority and responsibility for the patient’s care to another doctor.

4. Split referral: Transfer of authority and responsibility to several consultant doctors; during this time, the referring doctor must not intervene.

Examples of Referral Letters

After understanding the explanation above, you likely have a better picture of how to draft a proper referral letter. Below are several templates based on the criteria previously discussed.

Example 1: Emergency Referral (Midwife to Specialist)

Independent Midwife Practice

Jln. Cenda Ruwa 02, Banjarmasin

To:

dr. Rusmini Kurniasih, Sp.OG

Ulin Regional General Hospital, Banjarbaru

Respectfully,

We kindly request further examination and treatment for the following patient:

Examination findings:

1. Anamnesis: Abdominal pain and significant bleeding 6 hours postpartum.

2. Physical Examination: Pale, signs of shock, low blood pressure, rapid/weak pulse, cold extremities, and continuous vaginal bleeding.

3. Laboratory: Blood Type: A, Hb level: 7 gr%.

4. Temporary Therapy: 3L of Ringer Lactate fluid via peripheral intravenous access.

5. Misoprostol rectal 400 mg.

Thank you for your assistance.

Banjarmasin, January 15, 2013

Referring Midwife,

(Signature)

JALIA ABDAH, Amd.Keb

Example 2: Dental Referral

REFERRAL LETTER

To:

Drg. Yuniar Dahriani Siregar, Sp. PM

Prima Dental and Oral Hospital

Respectfully,

We kindly request further examination and treatment for the following patient:

Examination findings:

1. Anamnesis:

   • Complaint: Sores and white patches in the mouth for approximately 8 days.

   • Provisional Diagnosis: Primary Herpetic Gingivostomatitis.

   • Case: Patient was previously treated by a midwife (including mouthwash), but the mother cannot recall the medication name, and the sores have not healed.

2. Therapy/Medication given: Acyclovir 500 mg.

We look forward to your reply regarding this referral. Thank you for your attention.

Sincerely,

(Signature)

Drg. Febry Rahmadani

SIP No: 7832 64773799

Example 3: General Referral (GP to Specialist)

REFERRAL LETTER

To:

Dr. Budi Rahardjo, Sp.THT (ENT Specialist)

Jln. In Aja Dulu No. 564, Pondok Indah, Semarang

Respectfully,

We kindly request a consultation and further treatment for Mr. Bachruddin Bagaskara, 37 years old, presenting with anemia and hepatosplenomegaly. Laboratory results are attached. The patient has been provided with temporary therapy of [……] with a dosage of [……] mg.

We thank you for your kind assistance.

Semarang, March 11, 2022

Sincerely,

(Signature)

Dr. Heru Tri Sugiarta

General Practitioner

We hope these examples provide useful references for your administrative needs, whether for school assignments or professional purposes.