Clinical Referral Information Standard

Clinical Referral Information Standard

A standard for clinical referrals that supports faster, better patient care. Referrals to hospital are increasing as more people continue to live longer with a range of complex conditions. The Clinical Referral Information Standard is designed to improve the exchange of referral information from GPs to hospital consultants and other health care professionals, providing the required information in a consistent format.

On this page

Current release

Version: v1.0
> Standard model (Excel)
> Supporting documentation (external link to NHS Standards Directory)

From 01 January 2026, this standard will be owned and managed by NHS England and is made available for reuse or amendment under the Open Government Licence v3.0 (OGL 3.0). A review of the ongoing requirement for this standard will be undertaken by NHS England. Details on this and any update to the standard will be published on the NHS Standards Directory. If you have any questions or feedback relating to this standard, please email: england.standards.assurance@nhs.net.

 

About this standard

By using the standard professionals will have access to all relevant information in a timely manner, allowing for safer and more consistent care for people using health and care services. The information includes data about medications, previous history, allergies and current symptoms, as well as a patient’s concerns and expectations.

How it works

The primary care IT system is expected to be able to generate much of the information from the person’s record along with the referrers details, with the GP/professional adding the relevant clinical information.

The standard comprises 6 mandatory sections, 7 required sections (the information must be included where it is available), and 7 optional sections. The sections and the information in each is summarised in the table below:

 

Section Conformance (M/R/O) Description
GP Practice M Details of the GP practice where the patient is registered.
Patient Demographics M Patient details and contact information.
Individual requirements R Individual requirements that a person has, e.g. communication, cultural, cognitive, mobility needs and reasonable adjustments.
Referral Details M Details of where the referral is from and to
Reason for referral M Details of the reason for referral and its urgency along with information about the presenting complaints, management to date and other conditions or prboblems.
Alergies and adverse reactions M The details of any known allergies, intolerances or adverse reactions.
Medications and medical devices R The details of and instructions for medications and medical equipment the patient is using, including repeat medications, discontiunued medications, and medications prescribed elsewhere.
Safety Alerts R The details of any risks the patient poses to themselves or others.
Family History O Information about any family history deemed to be significnant to the health and care of the person
Social Context O The social setting in which the patient lives, such as their household, occupational history, and lifestyle factors.
Person concerns, expectations and wishes R A description of the concerns, expectations or wishes of the patient.
Legal Information R Legal information captured relating to patient care, such as consent to sharing information, legal power of attorney, safeguarding issues and mental capacity.
Examination Findings O Details of any relevant examinations of the person
Assessment Scales O Details of any relevant assessments done with the person
Relevant clinical risk factors O Details of any relevant clinical risk factors for the person
Investigations and results O A record of investigations and procedures requested, results and plans.
Information and advice given R A record of any information or advice given to the patient, carer or relevant third party.
Person completing record M Details of the person completing the referral
Distribution list O A list of other individuals to receive a copy of this communication.
Participation in research R The details of any research studies the patient is participating in.

“If someone’s been working for a period of time, in a form of therapy, for instance, where there’s an agreed plan for the locality when they may present in an emergency situation … then it’s really important for us to be able to see that that information and be able to act appropriately according to that because, you know, there isn’t and there shouldn’t be a stock response to that. These plans are designed to be individualised and personalised.  All services should be giving that personalised approach to care wherever possible. And a standard such as [PCSP standard] definitely moves us closer towards being able to do that. [Not acting on agreed plans] is a key finding in terms of emergency responses over the years where responses have been inappropriate.” – Mental Health Nurse

“Following a particular plan that’s been put into place will result in much better outcomes and prevent the sort of poor outcome which would otherwise be leading to an unplanned hospital admission.” – General Practitioner