How to refer for imaging: Your guide to what radiology teams need to know

Imaging referrals are common in general and musculoskeletal practice, and you may refer patients for imaging regularly. The referral you write is often a radiologist’s only insight into your patient's clinical picture. They usually won't have access to patient notes and may be reporting hours after the patient has left the department, or even days later.

If the referral is detailed and specific, the resulting report will answer your clinical question, and you and your patient will get the most from your imaging referral. If the referral contains only minimal details, the report will be more generic and might not carry the same clinical weight.

A referral is a clinical communication tool, not an administrative task. So what makes a good one?

Writing a good referral: what radiology departments want you to know

It can be easy to assume a radiologist has insight into a patient’s notes. If your practice is busy and you’re writing multiple referrals a day, you may not have time to consider the value of a detailed referral. Or if you’re new to referring, you might be unsure how much detail to include.

In most clinical settings, both within the NHS and in private practice, a reporting radiologist has limited or no access to a patient’s notes. They won't be aware of any medical complaints, surgeries, or previous imaging history unless they're told, and they rely on the clinical context you’ve written on the referral form. Add in outsourced reporting, and this is even more true.

So the more relevant information you provide, the better the report you’ll receive in return, and this starts with the clinical question you want answered.

Requesting a “knee MRI” ensures your patient receives an IRM of their knee. But when it comes to writing the MRI findings report, it doesn't give the reporting radiologist much direction.

Beginning a referral with “Knee MRI: 6 week history of medial pain post twisting injury, query meniscal tear” tells the reporting radiologist exactly where to look and what to look for. It may even influence the MRI sequence the radiology team uses, or help the radiologist decide whether you’ve requested the right scan.

Stating the clinical question you want answered is key. Simply adding “query meniscal tear”, “suspected rotator cuff tear”, or “? disc herniation” provides the radiology teams and the reporting radiologist with the information they need to provide you and your patient with the most useful and beneficial scan and report.

Relevant clinical information should accompany the question you want answered.

What to include in your referral:

• The mechanism of an injury: how it happened, when it happened, what they were doing.

• The symptoms: pain, swelling, stiffness, mobility problems.

• The specific location of the symptoms: medial, lateral, anterior, posterior, left, right.

• How long the symptoms have existed and whether they’re getting worse.

• Any red flags: night pain, weight loss, fever, neurological symptoms, abnormal bleeding.

• Relevant surgical history: previous arthroscopy, repairs, replacements, implants.

• Relevant injury history: prior fractures, cartilage damage, sprains, strains.

• Relevant medical history: current or previous cancer, diabetes, pregnancy.

Be concise, accurate and specific.

Leave out long, irrelevant medical notes not directly related to the symptoms in question, and avoid writing long specialist referral letter-type imaging requests, “This pleasant 49-year-old female presented in clinic”, etc.

Previous surgery and treatment history, even if years before, still remain relevant and important to know if they pertain to the current symptoms being investigated.

For example, in the case of a suspected meniscal tear, a reporting radiologist will find it useful to know if your patient has previously had a partial medial meniscectomy.

Or, if you’re investigating lower back pain and your patient has previously had a herniated disc, knowing this will guide the radiologist when writing their report. If you’re investigating neurological symptoms or cognitive changes, including details of previous strokes or aneurysm surgery will result in a more useful, detailed radiologist report.

As a GP, first contact practitioner, sports therapist, MSK clinician, or neurologist, you have your expertise, and it’s understandable that another specialist area or medicine might not be familiar to you.

Radiologists and radiology teams know this and are here to help you and your patient. In addition to imaging and creating imaging reports, their job is to collaborate on patient care.

It might be instinct to request specific X-ray views, for example, of the hand, or certain MRI sequences or techniques, such as T1-weighted vs T2-weighted or an upright, weighted knee MRI vs a supine.

But in most cases, the radiology department decides views and sequences based on your clinical question and their own protocols. If you write the referral and the clinical question well, the imaging team will get the technique right.

Of course, there will be cases when you want to add input, or you need something non-standard. If you do, speak to the department directly.

While the clinical question is important, red flags are critical. Note any of the following red flags, plus any others relevant to the patient, and mark your referral urgent:

• Pain that’s not relieved at night or by resting.

• Numbness, loss of reflexes or loss of mobility.

• Sudden or severe muscle weakness.

• Fièvre.

• Frissons.

• Perte de poids inexpliquée.

• Abnormal bleeding.

• Bladder and/or bowel dysfunction.

• Progressive neurological symptoms.

• History of cancer.

Some of these symptoms warrant going to A&E, but for urgent, non-emergency cases, noting red flags on the referral ensures that the radiologist prioritises reporting appropriately.

Most imaging referrals are smooth. You send the referral, the patient attends, the patient is scanned, the radiologist writes their report, and you receive the report. But sometimes, there’s some level of back-and-forth communication between you as a referrer and the radiology team.

Radiology departments have to adhere to IR(ME)R, the Ionising Radiation (Medical Exposure) Regulations, enforced by the CQC.¹ These regulations protect patients from the risk of harm from exposure to ionising radiation, such as during X-rays and CT scans. They’re designed to minimise unnecessary exposure, justify each exposure and keep exposure as low as reasonably practical by optimising diagnostic doses.

For IR(ME)R reasons, and in other cases where the scan is contraindicated (eg, metal devices incompatible with MRI) radiologists can and do reject inappropriate referrals. They may suggest a different imaging modality if the one requested won’t answer the clinical question. Rejected or redirected referrals are usually accompanied by a reason why, to help inform you and your patient.

This isn’t meant to be adversarial or antagonistic. It’s clinical governance working as intended, further underpinning the importance of a detailed referral. A rejected referral isn’t actually a rejection; it’s a real-time consultation and redirection to the best care for your patient.

• Clinical question: what do you want answered?

• Relevant notes on symptoms/injury: mechanism, location, duration.

• Specific location: side and site (left or right, which joint, which level).

• Red flags (if present, mark “urgent”).

• Surgical/treatment history.

• Relevant medical history: injuries, malignancies, pregnancy.

• Keep it clear and concise: one short paragraph is ideal.

An imaging referral is a clinical communication between two healthcare professionals. Even if you don’t speak or meet in person, it’s still a collaborative effort with the ultimate goal of treating a patient. The more specific and detailed you are about what you want to know, the more useful the answer will be.

If you’re unsure which details to include and which to leave out, radiology teams are available to help. Otherwise, ask the question, share the context and let the imaging specialists do the rest.

Scan.com’s clinical team is on-hand to help you and your patients. They give you the ability to refer for imaging nationwide via an easy-to-use portal, with in-built due diligence and referral support.