St Emlyn’s Lesson Plans
Making a useful referral
Practise referrals that make the concern, urgency and requested next step clear.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 26 minutes in total. With the reading alternative: about 18 minutes.
When we meet: We will practise referrals in triads. Everyone takes a caller turn, receives feedback and agrees what happens next.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: Two chairs facing away from one another for telephone practice; a blank SBAR or equivalent local template.
Run: 45-minute session plan · 30-minute option
Practise: use the card for observed practice and feedback. Allow time for both turns, or arrange a follow-on practice session.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 26 minutes in total. With the reading alternative: about 18 minutes.
Core preparation
Core listening · 17 min 54 sec
St Emlyn’s Podcast: Ep 56 - Intro to EM: How to refer a patient
A practical introduction to preparing a referral, making a clear request and escalating concerns.
Search for this episode by title in MedPod Learn if you want to record your listening there.
Prefer to read? Use How to refer a patient: written transcript instead of listening. Allow about 10 minutes.
Read the transcript under “Podcast Transcription” instead of listening. Then complete the same guidance check and referral task below. You do not need to do both routes.
https://www.stemlynsblog.org/podcast-how-to-refer-a-patient/
This 2015 discussion includes advice about persuading the receiving clinician. For this exercise, make the request openly, check understanding and agree who is responsible next. Complete the short guidance check and referral task below after either listening or reading.
https://www.stemlynsblog.org/podcast-how-to-refer-a-patient/
Read before the session
GMC: Delegation and referral · About 2 minutes
Read only paragraphs 18 and 21–24 on information, responsibility and recording a referral. Identify what the receiving clinician and patient need to understand before you finish the call.
https://www.gmc-uk.org/professional-standards/the-professional-standards/delegation-and-referral/delegation-and-referral
Prepare (allow 6 minutes): Using the chest-pain case below, write and practise a 30-second SBAR opening: situation, background, assessment and recommendation. Bring your wording on paper or on your phone. Use only the supplied facts; state what is still unknown.
Think about: What would you want the receiving clinician to understand from the first sentence of your referral?
Picture the scene
You have assessed a patient who needs surgical input. Before making the call, decide what you need from the surgical registrar and how soon.
By the end of the session
- Deliver a structured referral that separates facts from interpretation.
- State the urgency, requested action and remaining uncertainty.
- Agree and record the next steps when a referral is accepted, delayed or disputed.
After the session
- Ask the recipient of your next referral whether your request was clear.
- Notice one situation where an early advice call would help the patient.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 26 minutes in total. With the reading alternative: about 18 minutes.
Before learners arrive
- Check local specialty referral routes, escalation and transfer-of-care policy.
- Ask a colleague from another team which information helps them prioritise referrals.
- Provide the local referral and escalation contact sheet at the session. Learners do not need intranet access to complete the linked public preparation.
Equipment: Two chairs facing away from one another for telephone practice; a blank SBAR or equivalent local template.
Setup: Use triads: caller, receiving clinician and observer. Run three rounds so everyone is the caller once. Use case one, case two, then repeat either case with a new caller. Each eight-minute round has a three-minute call, two-minute observer feedback, two-minute retry and one minute to rotate. Chairs facing away from one another are helpful but not essential.
If the preparation has not been completed
Replace the opening sentence and structure activities (10 minutes). Display the SBAR headings and GMC paragraphs 18 and 21–24 linked in the preparation. Read them together for four minutes, then give pairs six minutes to prepare and compare a 30-second opening for case one. Start the three caller rounds at minute 10. For the 30-minute version, use the five-minute structure slot: two minutes to read the same paragraphs and three to draft the opening. Keep all three caller turns.
Suggested session plan
- 0–5 min — Opening sentence. Ask pairs to distinguish an observation, an interpretation and a request.
- 5–10 min — Agree a structure. Review situation, background, assessment and recommendation; adapt to urgency.
- 10–34 min — Three caller rounds. Use the two cases over three eight-minute rounds, repeating either case in round three. Everyone calls once, receives once and observes once; include feedback and a retry within each round.
- 34–40 min — Agree the next steps. Practise documenting acceptance, timeframe and interim responsibility.
- 40–45 min — Choose a follow-up action. Choose one phrasing change for the next referral.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Chest pain and an uncertain plan
A 55-year-old has ongoing chest pain and lateral ST depression. Observations are currently stable and troponin is pending. They take metformin and antihypertensive medication.
Add this information as the discussion develops:
- The receiving clinician asks whether this is simply a request to chase the blood test.
Ask the group:
- What is your opening sentence?
- Which information changes urgency?
- What must be agreed before ending the call?
Discussion notes
Points to draw out:
- Identify yourself and location, describe ongoing symptoms and ECG concern, and request urgent review with a clear timeframe.
- State the working diagnosis and uncertainty honestly. Verify medical history rather than claiming “no diabetes” despite metformin use.
- Describe treatment actually given, monitoring, pending tests, interim responsibility and escalation if review is delayed.
Common misconceptions:
- Reading every historical detail while burying the active risk.
- Claiming a treatment or diagnosis to make the referral more persuasive.
For a more experienced group: Ask how the referral changes if the patient becomes hypotensive before review.
The service boundary
A 28-year-old has right lower abdominal pain, vomiting and focal tenderness. You suspect appendicitis but have not completed the assessment for alternative causes.
Add this information as the discussion develops:
- The surgeon asks for more information; the patient is becoming more uncomfortable.
Ask the group:
- Which questions are legitimate clarification?
- What do you need to check yourself?
- How do you prevent a disagreement from delaying care?
Discussion notes
Points to draw out:
- Be clear whether seeking advice, urgent assessment or transfer of care: each can be appropriate.
- Reassess the patient, share relevant examination and pregnancy-testing information when appropriate, and acknowledge gaps.
- Agree immediate care and escalate unresolved disagreement to senior clinicians while maintaining responsibility for the patient.
Common misconceptions:
- Treating every question as hostility.
- Assuming the only successful outcome is admission.
For a more experienced group: Have the recipient summarise what they understood, then compare it with what the caller intended.
Important clinical points
- Do not invent or exaggerate findings to secure acceptance.
- A referral conversation does not by itself establish safe transfer: check understanding, action, timing and responsibility.
Practise with a partner
Use the card to rehearse the skill together. One learner performs. One learner checks the key steps and gives feedback. Then swap roles.
Make a useful referral · Early-career EM
Practise with a partnerRead the observer setup and allow time for both turns. Use the card alongside the lesson activity or in a follow-on practice session.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- What detail changes the urgency of each referral?
- How will you distinguish fact from your working diagnosis?
- How will you record a delayed review safely?
Key teaching points:
- Explain the relevant findings and uncertainty without burying the urgent concern.
- Say whether you need advice, assessment or transfer of care.
- Before ending the call, agree the next action, timeframe and who is responsible.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
SBAR can help organise a referral. Adapt the order to the situation; an immediate threat may need the urgent request first.
If the discussion drifts
What do you need the receiving clinician to do, and by when?
For a more experienced group
Practise a multi-team dispute while keeping the patient and interim plan central.
A 30-minute version
30 minutes: structure 5; three six-minute caller rounds 18; agree and document next steps 3; consolidation and choosing a follow-up action 4. In each round allow three minutes for the call, two for feedback and one to rotate. Use case one, case two, then repeat either case. Omit the retry, not anyone’s caller turn.
Evidence and guidance
- GMC: Delegation and referral — Effective January 2024; updated December 2024. Responsibilities and transfer of care.https://www.gmc-uk.org/professional-standards/the-professional-standards/delegation-and-referral/delegation-and-referral
- GMC: Good medical practice 2024 — Professional responsibilities, safe care and a supportive working environment.https://www.gmc-uk.org/professional-standards/good-medical-practice-2024
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO7 Manage complex situations in the workplace
Communication, escalation and continuity of care.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-08-08 · Iain Beardsell.