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You may refer a patient, or you may receive a referral from a colleague. If you receive a referral, you should address the reasons for referral and advise the patient to consult their regular practitioner for routine eye care.
When to refer
If you observe a sign or symptom of injury or disease which you cannot manage within your competence or scope of practice, you should refer the patient to an appropriate practitioner who is registered with a statutory regulator.
You should consider national and local guidance on referrals.
The National Institute for Health and Care Excellence recommends that patients with signs of possible glaucoma or related conditions, identified during  a routine sight test, should have additional tests before they are referred for a diagnosis.294 The Scottish Intercollegiate Guidelines Network has published guidance on glaucoma referral and safe discharge.295 
If, in your professional judgement, you do not need to refer the patient, or it is impractical to do so, you may decide to manage the condition yourself.296
If you decide not to refer the patient you must record:
  1. a sufficient description of the condition
  2. the reason for deciding not to refer on this occasion
  3. details of advice or treatment given to the patient.
If you decide not to refer the patient you should inform the patient’s GP of any relevant findings, if the patient consents.
The welfare of the patient must not be compromised.
You must refer patients with appropriate urgency. If there are local protocols in place for referrals, including emergency or urgent referrals, you should follow these. If in doubt, you should seek advice from the on-call ophthalmologist to determine the most appropriate pathway for the patient. Where there are no local protocols, guidance on which conditions are considered an emergency and which are considered urgent can be found in Annex 4 Urgency of referrals table.
Patients have a right to be fully involved in decisions about their care.
If the patient does not wish to be referred you should:
  1. ensure they understand why the referral is necessary
  2. record a full account in the patient records
  3. obtain the patient’s signature on a declaration that they do not wish to be referred.

Whom to refer to
You must only refer patients to a practitioner with the appropriate qualifications and registration.297
When you refer a patient, you also transfer responsibility for the relevant part of the patient’s care.
If the patient is not registered with a GP, or wishes to see a doctor privately, you should give them the referral letter and tell them to register with a GP or to arrange a private appointment with an appropriate doctor, for example an ophthalmologist. Alternatively, you can send your advice by recorded delivery to the patient and enclose the referral letter.
Telling the practitioner
You should write a clearly worded referral and include:
  1. relevant details from the eye examination
  2. the reason for referral, including images where appropriate
  3. details of discussions with the patient and any with the practitioner to whom you are referring
  4. the level of urgency.
If the patient is already receiving care for the observed sign of injury or disease you should notify the practitioner who is caring for them if you believe your findings might provide additional, useful information.
If you send the referral letter directly to the practitioner to whom you are referring, you should ensure that the patient’s GP is kept informed. This may be relevant in an emergency or where you use a referral centre.
Telling the patient
If you are referring the patient to a doctor, the law says you must give the patient a written statement of the reasons for referral, immediately following the sight test.298, 299 If you cannot write the referral letter immediately following the sight test, you can write the reason for referral elsewhere, for example on the patient’s prescription.
You should ensure that the patient understands the urgency of the referral.
You should tell the patient when they should expect to hear about their referral and what to do if they do not hear within that timescale. 
You should tell the patient what to do if their symptoms get worse before they are seen.
You should give patients copies of any correspondence relating to them so that they are clear about their condition and the care they are receiving. This can also be useful in case the original correspondence goes astray.
If the patient is not legally responsible for their own care, you should copy the letter to the person who is legally responsible.
You should provide copies of correspondence and any relevant supporting information in an accessible format.
You should ask young people who have the capacity to consent to treatment whether they would like to receive copies of information about themselves, and how they would like to receive this.
You should not copy a letter to a patient if:
  1. they decline a copy
  2. the letter contains information about another person who has not given their consent for you to disclose this information (other than if the patient originally provided this information or if you remove this information from the copy letter)
  3. you feel it may cause harm to the patient. Giving bad news is an insufficient reason for withholding a copy of the letter.
Sending the referral
If you post the copy of the referral letter to the patient:
  1. find out where they would like it to be sent
  2. use the patient’s full name in the address and check with them if they share the same name as someone else at that address, and how to avoid confusion with other family members.
When you send a referral, make sure it is sent by a secure method or the patient has given consent for it to be sent by an alternative method.
Recording the referral
You should keep copies of all referral letters and a note of the discussions held with the patient, including the advice you gave.