The referral letter is the most common task in the OET writing sub-test for nurses — and the most commonly misunderstood. Candidates polish their grammar for months, then lose Grade B on something no grammar book covers: choosing the wrong case notes to include. In the letters our correction team marks, selection errors outnumber language-driven failures roughly three to one. This guide fixes the real problem. You’ll get the four-paragraph structure examiners reward, a reliable method for deciding what goes in and what stays out, a complete sample letter with the reasoning behind every sentence, the language toolkit that makes expansion automatic, and a 45-minute exam routine that holds together under pressure.

What the Examiner Is Actually Scoring

Your letter is assessed by two independent examiners against six criteria — Purpose on a 0–3 band, the other five on 0–7 bands:

Read the table again and notice what it implies: five of the six criteria score communication decisions, not English. A grammatically flawless letter that buries its purpose, includes irrelevant social history and omits the allergy will score worse than a letter with a few slips that selects and organises perfectly. Grade B typically requires 5s and 6s across the board — and because the criteria aren’t averaged forgivingly, one collapsed criterion (almost always Content) sinks the sub-test on its own. The full scoring mechanics are in our score calculator guide.

The Anatomy of a Referral Letter

Before the paragraphs, the frame. OET expects standard professional letter conventions, and they are free marks under Organisation & layout:

• Recipient’s name, title and address exactly as given in the task — copy them; misspelling the recipient is a needless first impression.
• Date (the date of writing, usually the discharge/referral date in the notes).
• Salutation: “Dear Dr Sharma,” for a named recipient; “Dear Colleague,” or “Dear Sir/Madam,” when the task gives only a role.
• A “Re:” line with the patient’s full name and date of birth — it removes the need to waste body words identifying the patient administratively.
• Sign-off: “Yours sincerely,” with a named recipient; “Yours faithfully,” with Sir/Madam. Sign as your role in the notes: “Charge Nurse”.

The Four-Paragraph Structure

The opening formula that consistently scores well on Purpose: “I am writing to refer [Name], a [age]-year-old [occupation or relevant descriptor], for [the specific assessment or management you are requesting].” Fifteen words in, the reader knows the letter’s entire job. Compare the letters we mark that open with “The above-mentioned patient was admitted to our ward on…” — grammatically fine, and the examiner still doesn’t know why the letter exists.

The Case-Note Selection Method

OET case notes always contain more information than the letter needs. That surplus is not sloppiness — it is the test. Here is the method that survives exam pressure:

1. Fix the recipient’s role in your mind before reading the notes. A cardiologist, a district nurse and a dietitian receiving the same patient need different subsets of the same notes. Everything filters through one question: what does this specific professional need in order to act?
2. Sort every note into three piles as you read: must include (justifies the referral or changes the recipient’s decisions), could include (context, if words allow), exclude (someone else’s business).
3. Non-negotiable inclusions: documented allergies — omitting one is a serious clinical communication failure and examiners treat it that way; the findings that triggered the referral; current medications relevant to the recipient’s decisions; the explicit request.
4. Default exclusions: routine nursing care (repositioning schedules, standard observations), normal or irrelevant test results, administrative details already in the Re: line, and social history — unless the letter’s purpose makes it relevant (a home-support referral reverses this instantly).

That last clause deserves its own sentence, because it is where mechanical rule-following fails: relevance is set by the task, not by the category of information. “Lives alone, two flights of stairs” is noise in a cardiology referral and the entire point of an occupational-therapy referral. Candidates who memorise “never include social history” write worse letters than candidates who ask the recipient-role question every time.

Sample Referral Letter, With the Reasoning Visible

Scenario: a 62-year-old patient admitted with a severe COPD exacerbation; echocardiogram shows new cor pulmonale; ongoing oxygen requirement. Referral to a respiratory physician for specialist review and home-oxygen assessment.

Dear Dr Sharma,

Re: Mr Thomas Nguyen, DOB: 14/06/1962

I am writing to refer Mr Nguyen, a 62-year-old retired truck driver, for specialist review of newly identified cor pulmonale and assessment for long-term home oxygen therapy.

Mr Nguyen was admitted on 18 April 2025 with a severe exacerbation of his known COPD, triggered by a respiratory tract infection. On admission he was in type 2 respiratory failure and required non-invasive ventilation, which was successfully weaned by day three. A recent echocardiogram demonstrated right ventricular hypertrophy and dilatation consistent with cor pulmonale — a new finding requiring your review.

His history includes hypertension and Type 2 diabetes, and he is an ex-smoker with a 40 pack-year history. Please note a documented allergy to aspirin, which causes bronchospasm. He currently maintains oxygen saturations of 90% on one litre of supplemental oxygen at rest, desaturating to 83% on exertion.

Your specialist assessment and guidance regarding his ongoing respiratory management would be greatly appreciated.

Yours sincerely,
Charge Nurse

Now the decisions, paragraph by paragraph — because the decisions are what you are actually being marked on. Paragraph one names both referral purposes (cor pulmonale review and oxygen assessment); a vague “for further management” would cap the Purpose band. Paragraph two compresses the admission ABG story into “type 2 respiratory failure” — enough for a respiratory physician, who does not need the raw values retold — and spends its detail budget on the echo finding, because that is what the referral turns on. Paragraph three keeps three history items that shape respiratory management, prices the smoking history in pack-years (the unit the specialist thinks in), and places the aspirin allergy exactly where the reader will act on it. Both saturation figures survive because they are the evidence for the home-oxygen request. What was cut: the nebuliser regimen, the antibiotic course, the normal urinalysis, the daily-checking neighbour — all true, all ward business, none of it this specialist’s decision material.

The Language Toolkit: Expanding Notes Into Sentences

“Expand the relevant notes into complete sentences; do not use note form” is an instruction with a technique behind it. The pattern: subject + full verb + the clinical fact + its significance where needed.

Useful sentence stems, by paragraph: Purpose — “I am writing to refer… / to request…”. Situation — “He was admitted on… with…”, “Investigations revealed…”, “Her condition improved following…”. Background — “Her relevant history includes…”, “Please note a documented allergy to…”. Request — “I would be grateful if you would assess…”, “Your assessment regarding… would be greatly appreciated.” Tense logic: past for events during the admission, present for the patient’s current status, and present perfect for the bridge between them (“has made steady progress”, “has been commenced on sertraline”). Universally understood abbreviations (COPD, BP, DVT) are fine between professionals; the case notes’ shorthand (Hx, Mx, NAD, c/o) never migrates into your sentences.

Five Mistakes That Keep Letters Below Grade B

• Note-form with a verb bolted on. “Patient BP 158/94, commenced O2” is still note-form. Expand fully, once per fact — then stop.
• Chronological data-dumping. Retelling the notes day by day instead of organising by what the recipient needs first. The notes’ order is the ward’s order, not the reader’s.
• Omitting the allergy. The single most expensive missed note in OET writing — a Content-band hit that no amount of elegant language recovers.
• Vague purpose lines. “For further management” tells the reader nothing. Name the condition and the requested action.
• Overshooting the word count. The target is 180–200 words in the body. A 260-word letter is not a generous letter; it is failed selection made visible, and Conciseness pays for it.

Your 45 Minutes in the Exam

1. Minutes 0–5 (fixed reading time): identify the recipient and their role, the task’s exact request, and mark your three piles in your head — must, could, exclude. You may not write yet; you can absolutely decide.
2. Minutes 5–10: thirty-second skeleton — one line per paragraph naming its contents. This is where the selection method runs.
3. Minutes 10–35: write. Purpose sentence from the formula, then paragraph by paragraph from the skeleton. Do not count words as you go; a four-paragraph skeleton built from selected notes lands in range naturally.
4. Minutes 35–45: two proofreading passes with different jobs. Pass one, content: allergy in? both referral reasons in? request explicit? Pass two, language: tenses, articles, the recipient’s name spelled as given.

Frequently Asked Questions

How strictly is the 180–200 word count enforced?

There is no automatic word-count penalty for drifting slightly either side. But a significant overshoot almost always reflects poor selection, and that is penalised through Content and Conciseness. Treat 200 as a design constraint while planning, not something to count mid-sentence.

What’s the difference between a referral and a discharge letter?

A referral asks the recipient to do something — assess, review, take over an aspect of management — so it is organised around the evidence for that request. A discharge summary informs the GP of what happened and what has already been arranged. Similar frame, different purpose line, and near-opposite selection logic: follow-up arrangements dominate a discharge letter and barely feature in a referral.

Should I invent information if the notes seem incomplete?

Never. Everything in your letter must come from the case notes. If something seems missing, that is the task telling you it isn’t needed. Invented clinical details damage Content and can read as unsafe communication.

Can I use bullet points for the medication list?

No — “use letter format” means continuous prose throughout. Run medications into a sentence: “Her discharge medications include celecoxib 200mg daily, enoxaparin 40mg subcutaneously once daily, and paracetamol as required.”

How many practice letters do I need before test day?

Volume matters less than feedback. Ten letters written and never marked embed the same selection errors ten times. The pattern that works: write one, get it assessed against the six criteria, fix the named weakness in the next one. Most candidates who follow that loop reach stable Grade B letters within six to eight marked attempts.

Practise With Full Case Notes and Model Answers

Reading about structure is step one; writing against realistic case notes under a 45-minute clock, with feedback against the real criteria, is what moves your band scores. Our OET Writing Samples for Nurses course now pairs every test with a complete lesson — authentic case notes, a model answer, and a paragraph-by-paragraph explanation of every selection decision — followed by a timed practice test. Write your letter, post it in the comments, and our team will evaluate it against the six criteria examiners use.